Bybrook House Nursing 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

At our last assessment we found safety concerns with the environment. Window restrictors had not been fitted and operated safely. Following the assessment the provider gave us assurance all window restrictors would be checked, repaired and if needed replaced. At this assessment we found there were still concerns with some window restrictors as they were not tamper-proof. Staff had used keys to remove some restrictors from their fastenings in order to open the window wide. We also found some rooms that still had no restrictor fitted. Whilst there was nobody assessed as being at risk of leaving the service through windows, this was a risk to people’s safety.

At our last assessment we found some areas of the environment needed maintenance. At this assessment some maintenance had been completed, however, 2 areas of the home still needed replacement flooring. The current flooring was damaged and worn which meant it did not cover the concrete underneath creating a trip hazard and risk of cross infection. Whilst these areas were not used by people or visitors, the doors were not locked which meant they could be accessed by anyone which increased risk of harm.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

At our last assessment we found some areas of the service were not able to be thoroughly cleaned. This was because the areas had exposed porous surfaces due to damaged flooring and flaking paint. At this assessment some work had been completed to re-decorate 1 sluice room, however, another sluice room and the laundry were still in need of replacement flooring. These 2 areas could not be cleaned thoroughly which increased the risk of cross infection.

People’s rooms and communal areas accessed by people were clean. There was a system to make sure people’s rooms were deep cleaned monthly. People said they were happy with the cleanliness of their rooms including their en-suite bathrooms.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

At our last assessment we found some shortfalls with how medicines were managed. At this assessment we found the provider had taken action to address those shortfalls, however, we found medicines were still not being safely managed. For 1 medicine that needed additional storage checks, staff had not checked this medicine for 2 weeks. The registered manager was not clear why staff had not carried out the checks for this medicine. People’s medicines administration records (MAR) were not always accurate in relation to what they had been prescribed. Some medicines that had been discontinued by the person’s GP were still recorded on the MAR. Staff had not updated the records. For another medicine staff had handwritten that it was ‘as required’, however, this was not accurate as the person was prescribed it daily and the handwritten instruction was incorrect. This put people at risk of harm as staff did not have the correct prescribing instructions to follow.

Topical creams, eye drops and liquid medicines now had a date recorded when they had been opened. This helped staff know when they would need to be disposed of. Staff had received medicines training and had their competence to administer medicines checked.

People told us they were happy with the support they had from staff to manage their medicines.