Byron Lodge Care Home Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. This was an area for improvement. Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. Lessons were learned when things went wrong. Medicines were administered and recorded safely. Medicines policies had not always been followed by staff in relation to administering PRN (as and when required medicines). Staff were recruited safely and were supported through training, there was a plan in place to make sure they had ongoing support in the form of supervision and appraisal meetings. There were enough staff to support people safely. Ongoing training made sure that staff had the skills needed to support people. Accidents and incidents were reviewed and actioned by the management team, safety checks were undertaken by staff. The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection. We were assured that the provider was working to improve safety through the layout and hygiene practices of the premises.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. Relatives told us they were kept well informed when there were incidents, changes or concerns.

Staff knew how to report accidents and incidents and knew how lessons learned were shared with them. Nurses and nursing assistants reflected on their own practice regularly and supported others to do the same so they could learn lessons when things went wrong, minimise the risk of the same thing happening again and strive for continual improvement.

The provider had a culture, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. Accidents and incidents were reviewed and actioned by the management team, safety checks undertaken by staff including maintenance, were audited and checked by the management team. This enabled the management team to make continuous improvements.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. People told us, “The chiropodist comes to see me as I am diabetic, and the staff look after my nails” and “The staff make sure I see a doctor when I need one.”

The management team explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. As well as good ongoing work with the GP and frailty nurse, Tissue Viability Team, Speech and language Therapists and other health and social care professionals. Staff told us about a person who had anxieties that led to them getting upset and the person declining personal care. The service worked in partnership with the dementia nurse specialist and plans were put in place to ensure the person gets the care and support they need. The strategy is aimed at preparing the person for what is about to happen, for example, a staff member will go to them and say, “we will be back in 10 minutes to help you with your personal care”. Staff told us this had worked well and they are now working with community teams to prepare for the person to return to their own home.

A healthcare professional told us, “All staff within Byron lodge are very good at assessing and managing patients care needs. They are good at escalating concerns in health deterioration or changes in medical condition.”

The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. Safety was managed, monitored and assured. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, hospital passports were in place. A hospital passport helps people including people to give hospital staff important information about them and their health when they go to hospital.

People were safe and were protected from harm. People told us, “I feel safe and happy with the staff” and “The staff are here to help me and that makes me feel safe.” A relative said, “I know she is safe because the staff know her, and they are straight on the phone if there is any change.” Staff were attentive to people’s needs and made sure they were safe as they carried out their daily routines. Relatives told us they were confident to raise any concerns and knew that they would be responded to.

Staff had received adult safeguarding training and had refreshers every 3 years. Safeguarding training included safeguarding children. Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “If I thought someone had been abused, I would inform the nurse, take photos, and report it to the manager. I have every confidence that the manager would deal with it. If the manager wasn’t in or I wanted to make sure my concerns had been acted on, I would inform the director.”

We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times through an online portal. Safeguarding concerns had been reported appropriately. The management team told us they had positive working relationships with the local authority and other statutory partners and were confident to seek advice and report safeguarding issues in a timely way. The management team had reviewed processes and learnt lessons from safeguarding incidents. The management team discussed safeguarding matters with the staff team 3-4 times a week. This ensured that they were aware of concerns and the staff understood the escalation process.

People gave us positive views about how staff managed risks well. The service used equipment to help maintain people’s safety. A person told us, “I feel very safe, staff are there when I need them.”

Staff knew people well and were confident they could identify any changes in people’s presentation that may be of concern. The management team explained that safe systems had been put in place to enable to people who smoked to smoke in an area of the garden. A staff member supported them when they used the area to ensure safety when lighting and extinguishing their cigarettes. A staff member told us, “It is my responsibility to read the updated care plan before I give anyone personal care, that’s on me and I make sure I do it, otherwise I may be putting that person at risk and maybe me too.”

We observed that risks were well managed. People were supported to move around the service safely and were supported to spend time where they chose. People were given food and fluid in a consistency which was in accordance with their assessed needs (including diabetic diets). The food was well presented, and people seemed to be enjoying the experience. Staff checked on people eating in their rooms to make sure they were eating and were safe.

Risk assessments were clear, comprehensive and up to date. They provided enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. Staff had access to the risk assessments and care plans. Risks in relation to pressure area care were adequately monitored and mattresses were at the correct settings to maintain people’s skin integrity. People had been frequently repositioned in accordance with their care plan. Epilepsy risks were documented, understood or identified. Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. However, catheter care risks had not always been effectively assessed and mitigated in a timely manner. A person had moved to the service 7 weeks before we carried out the assessment, they did not have a continence or catheter care risk assessment in place. The person did have a care plan in place which showed they needed support to drink 1500ml of fluids a day. Records showed that they had not met this target 5 times within 8 days. They had not been offered 1500ml or more of fluids on 2 days. Monitoring of fluids was an issue when we carried out the last inspection of the service. There were building related risks relating to fire safety which were being reviewed following an inspection undertaken by the fire service. Contractors had been booked to complete works to ensure that fire risks were effectively managed.

People benefitted from an environment that was well maintained and clean. Radiators were covered and were switched off due to the hot weather, people had access to fans to cool them down if they required them. There were window restrictors to all windows. The corridors were light and unobstructed. Toilets and bathrooms were clean, sanitised, and fresh, with pull cord alarms accessible and in reach.

We spoke with the provider about fire risks, the service had been inspected by the fire service at the beginning of June 2024 and been served a deficiency notice. The management team explained they were working to address the concerns raised by the fire service. Since the fire service visit, the provider had contracted a specialist company to visit the service and are going to carry out a new fire risk assessment.

A redecoration programme was in place, some rooms and areas had yet to be completed. These areas looked tired. The areas already completed appeared to be well maintained. Maintenance tasks appeared to have been completed in a timely manner. Rooms were clean and tidy and had been personalised in accordance with the person’s wishes. Fire exits were clearly visible and unobstructed. Evacuation sledges were clean and hung on the walls to each floor. The lift was clean and in working order.

The provider had systems and processes in place to detect and control potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care. Essential servicing and maintenance of the gas, electric, lift, fire alarm system, emergency lights, moving and handling equipment had taken place. However, the fire checks that had previously been completed had not detected the concerns raised by the fire service.

People gave us mixed views about whether there were enough staff on duty at the service. Comments included, “There is generally enough staff around”; “I have had to wait if they are busy, but not too long” and “Not all the time.”

Staff told us there were enough staff on duty to provide safe care. A staff member said, “I think there are enough staff here, we don’t rush, we take our time with residents, many are frail and in bed and need to take things very gently, we don’t rush them.” Staff told us about the training and support that provided them with the skills they needed to support people safely. Training was provided online as well as face to face, depending on the topic. For example, staff had recently had fire training face to face and were confident they would know what to do in an emergency. When any online training was due for renewal; staff received an email to remind them to keep their training up to date. Some staff had specific training to support people with a learning disability and to manage adverse behaviours. Staff were enthusiastic about learning new skills and keeping their training up to date. The nursing assistant has worked closely with SaLT (Speech and Language Therapists) and Tissue Viability Nurses in order to learn new skills and update their own practice. Staff were knowledgeable about the people they were supporting and had a good understanding of the management of health conditions such as diabetes, epilepsy and wound care.

We observed there were enough staff on duty to support people. Call bells were answered quickly. Duty rota’s were completed in advance and a few gaps were filled by staff completing extra hours and agency staff were used when needed.

Staff had been safely recruited. We examined 5 staff files and all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council and the provider had made checks on their personal identification number, their registration status and their renewal date. For the agency staff working at the service, there were detailed staff profiles in place to demonstrate safe recruitment and mandatory training. Staff had regular supervision meetings and induction was a mixture of training and shadowing experienced staff to gain confidence and experience. The provider’s training matrix showed that most staff had completed mandatory training. Nursing staff had completed additional training to ensure they had the skills and knowledge to meet people’s nursing needs. There were enough staff deployed to meet people’s needs and provide safe care. The service used a dependency tool, this had been updated monthly, which helped the manager to calculate the number of staff needed.

People told us their bedrooms and the service were clean and tidy. Comments included, “A lady come in and cleans my room every day” and “It is always nice and clean.”

Staff told us they had sufficient equipment and PPE (Personal protective equipment) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “Infection control is important to everyone, if you don’t keep people safe and clean, you risk everyone’s health, even your families at home. We limit the spread of infection by wearing PPE and changing gloves and aprons when we start different tasks.”

We observed that the staff were using PPE effectively and safely. We were assured that the provider was promoting safety through the layout and hygiene practices of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment.

The provider had systems and processes in place to assess and manage the risk of infection. They were able to detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. The provider had a daily cleaning program in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE in place to keep people and staff safe. The kitchen areas were clean and well managed.

People received their medicines safely. A person said, “The staff support me with my medication.” Another person told us, “Staff come in and give me my medication, they will explain what it is for.” We observed the staff were polite, gained consent, and recorded the administration of medicines on the medicines administration record (MAR).

People received their medicines from trained staff. The staff informed us they received training. The management team told us staff were competency assessed to handle medicines safely. People were supported by the local GP and frailty nurse.

The provider had systems and processes in place to manage medicines which were not fully robust. Some people were prescribed medicines to be taken only when required known as (PRN) medicines. Guidance (PRN protocols) were in place to help staff give these medicines consistently. There was a medicine policy in place, however this was not always followed. For example, reasons for PRN medicine being given had not been recorded, which meant the effectiveness of the PRN medicine was not always monitored and recorded. Nursing staff explained this information used to be recorded on the back of the MAR chart, but the recent MAR charts sent from the pharmacy did not have the table on the reverse. We discussed this with the manager who planned to speak to the pharmacy. We observed that prescribed thickening agents used to thicken fluids to support safe swallowing had been used incorrectly. Each person had their own stock of prescribed thickener. However, it had become common practice that one person’s thickener was used for everyone that needed it. We discussed this with the manager who made immediate changes to ensure people only received their own thickening agent. Medicines care plans and risk assessments were detailed and person-centred. They provided good information to support staff to understand people's care needs and linked to care planning for specific conditions. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits.