Byron Lodge Care Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to management of medicines. Improvements were found at this assessment and the provider was no longer in breach of this regulation. The provider had taken action to ensure the proper and safe management of medicines.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The management team undertook investigations when things went wrong and put measures in place to minimise the risk of similar issues arising in the future.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Pre-admission assessments were undertaken prior to people moving into the service and included information from people, their relatives and healthcare professionals. One person was going through the admission process on the day of our visit. Their relative told us the staff had been, “Marvellous.” One person’s toenails needed some attention. We discussed this with staff on the day of our visit.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The new manager had good knowledge of safeguarding and reporting procedures. During our visit we saw staff treated people respectfully and supported them to remain safe.

Staff received training and followed the provider’s policy to make sure people were safeguarded from the risk of harm and abuse. People told us they felt safe and we saw caring interactions between staff and people using the service.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

Overall, the service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people’s care had been identified and managed to keep people safe.

However, we found some shortfalls in people’s care plans. For instance, where people used a hoist, their care plans did not include a record of the hoist sling loop configuration that should be used, or serial numbers for the hoist sling to be used. Records did not always reflect that people were provided with fortified meals. Repositioning charts were not always completed when staff helped people to reposition in bed. It was not always clear that people who were given their drinks in spouted beakers has been assessed as needing these, and this need was not always documented. This could increase the risk of choking for some people. However, it was clear that staff knew people well, and this helped to mitigate the risk of harm

Most relatives were confident that staff managed risks well. For instance, a relative said, “Safe, yes, the door is open and [staff] talk to [my family member]. Everything they [staff] do, [my family member] is safe”. One relative said the only thing they were worried about was that there were staff who were not as aware as they should be of their family member’s needs and preferences around food and drinks.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The new manager undertook daily walk rounds of the service and additional checks were made by members of the provider’s management team.

The reception area of the home was awaiting refurbishment. Some of the walls and woodwork in the communal spaces required refreshing. There was an ongoing programme of maintenance planned to address these and other areas identified for refurbishment.

Signage was dementia friendly to help people to find their way around the home. Some signs included braille to support people with visual impairment.

The provider had installed CCTV externally and in some communal areas, such as the entrance lobby. The new manager told us people and visitors were asked for consent in relation to this. The service followed good practice guidance for people who lacked capacity. The service had also used footage as a ‘lessons learnt’ tool to identify how incidents occurred and how practice could be improved going forward.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff were recruited safely, additional checks such as, the right to work in the UK and verification of registered nurses’ PIN numbers (personal registration numbers assigned by the Nursing and Midwifery Council) were conducted and continually reviewed.

People and relatives felt there were generally enough staff to meet people’s needs. People told us staff came quickly when called. Although, 1 relative said, “You could always argue for more staff”, another relative said, “[Staff] are constantly passing”. The activity coordinator told us they made sure to spend one to one time with people who spent a lot of time in their rooms.

Staff told us they were provided with training that supported them to provide safe care that met people’s individual needs. Staff received both, online training and practical face to face training. Additional courses were sought in response to people’s individual needs.

The service assessed and managed the risk of infection. Housekeeping staff worked hard to make sure the service was clean, and audits were completed to make sure staff followed the provider’s infection prevention and control policies. Staff used and disposed of personal protective equipment (PPE) appropriately.

People and relatives were spoke positively about cleanliness in the home. One relative told us, “I am happy with the cleanliness. [My family member] is safe and the staff are very good.” Another relative said, “It’s clean and there’s never lasting smells.”

Improvements had been made to make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people and, where appropriate, those close to them in planning, including when changes happened. Staff had completed medicine training and their competence and practice were assessed on a regular basis.

Some people required their medicines to be administered covertly (without their knowledge, but within their best interests). The service followed legal guidelines for covert medicine administration.

We saw a staff member supporting people with their medicines. This was done in a caring way, at the pace of each person and taking people’s individual communication needs into account.