Byron Lodge Care Home Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

There was an inclusive and positive culture of continuous learning and improvement. This was based on meeting the needs of people who use services. Leaders proactively supported staff and collaborated with partners to improve the service and improve the quality of care being delivered to ensure it was safe and person-centred.

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.

The management team were clear they wanted to improve the service and outcomes for people both in their experiences and the environment. They said, “Key priorities include redecoration throughout the building and to personalise people’s bedrooms more. I have ordered garden furniture this morning for our residents to sit out in the warmer weather and enjoy. But this is once we have done all we can to meet the needs of our residents and give them a comfortable home to live in. This is their home.”

The provider and the manager had kept up to date with local and national developments within health and social care and had attended forums, training and signed up to well known, reputable websites to find advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need and what commissioners and regulators expect. Nursing staff explained they used resources such as NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary) to ensure they were following the latest clinical guidance and best practice. Daily shift handover meetings took place and these were documented.

The management team knew people well and were passionate about making changes to improve people’s lives. Managers were described by staff as “Supportive and approachable”. A staff member said the manager was “Absolutely fantastic.”

The provider had not yet recruited a new manager. There was no registered manager in post. The previous registered manager had left in October 2023. The home was being managed by the deputy manager who was supported by the area manager. The management team led with integrity, openness and honesty to ensure care and support was delivered inline with people’s wishes, expectations to embody the culture and values of the workforce and organisation. People and relatives told us the management team had an open-door policy and made time to talk with them. A visitor told us, “I would be happy to raise any concerns and have in the past and it was sorted straight away.”

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “The management are very open about the areas of the home that need improvement, like the decoration, and they are very approachable and honest and act on issues as soon as they are raised.” Another staff member told us, “I am confident to raise any concerns, whether it’s a safeguarding matter about a resident or something wrong about the company because risk involves everyone, everyone is at risk if you don’t do something about it.”

The provider had systems and processes in place to foster a positive culture where people felt that they could speak up and have their voices heard. Complaints processes were available.

The provider told us they were well supported by a human resources company to provide employment advice. They utilised the expertise of the company when required. The management team said, “Key achievements would be about staff retention and the positive staff feedback we get. I tell staff they are doing a good job, and they are appreciated.”

The provider had processes in place to ensure there was an inclusive culture. Staff said the culture of the service was open and inclusive and they all worked together well as a team. The workforce was diverse and support was in place for staff. Flexible working was in place to support staff, staff gave us examples of how this had supported them in relation to childcare responsibilities.

Staff told us they liked working in the service and the manager and provider were supportive and approachable. Staff we spoke with were confident that they could discuss any concerns with the management team and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. The management team said, “Improvement to care plans on PCS [electronic care planning system] has made a very positive impact with the attention to person-centred detail and our auditing is better and more regular.”

The provider had an audit programme in place. Regular audits were undertaken by the management team. If audits identified any areas of concern, actions were identified and actioned when required. Actions taken as a result of the last inspection had been completed, with the exception of developing risk assessments in a timely manner when people moved to the service, which we have reported about in safe. Some care plans were more person-centred than others. Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. The management team had correctly submitted notifications to CQC. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so.

People and relatives told us about visits to the service from community nurses and other healthcare specialists. A person told us they go out of the service with their relative. A visitor told us, “I would like the garden to be nicer so they could sit outside and enjoy the sun.”

The management team received peer support from forums such as provider forums and social media groups. Nursing staff utilised support from clinical supervision and from following national good practice guidance. All staff worked closely with visiting health and social care professionals. Staff explained how they welcomed visitors and visitors. The service welcomed community groups and visiting clergy and activities such as school choirs took place.

The local authority quality assurance team told us they had been working closely with Byron Lodge to make improvements at the service. The reports on progress showed that actions had been addressed following previous visits from the quality assurance team and since the last inspection of the service in March 2023.

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement. The local authority had been to visit the service in October and December 2023 and April 2024. The service had also been visited by the fire service and needed to make improvements to fully meet fire regulations.

The provider told us, that they and the service were looking at ways to innovate. We discussed complaints with the management team. They explained they discussed complaints as a management team and they “Look at any complaint as a positive opportunity to improve our service. We stay objective and always give feedback to the complainant, even if we haven’t been able to resolve the issue. We try to encourage face to face resolution as quickly as possible, certainly within 28 days, usually a lot sooner. A recent example is a [relative] who was very cross because [they] felt [their loved one] wasn’t drinking enough fluids. So we bought a variety of different beakers with measurements up the side and [person] chose which [they] preferred, and the [relative] was delighted. We have since offered several other residents these beakers and other families have been very happy. We have also been buying in different drink flavours; elderflower, lime, and we encourage options (dietary needs allowing) including lemonade and ice-cream floats.”

The provider had systems and processes in place to continuous learn, innovate and improve the service. Surveys had been sent to gain feedback from people, relatives, staff and professionals in July 2024, the provider had not yet received the results. Meetings held with people also captured feedback and suggestions. Complaints were appropriately managed. The service had received a lot of thank you cards and compliments from relatives, particularly for those that had been cared for at the end of their life.