Bybrook House Nursing Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in repeated breach of legal regulation in relation to governance at the service.

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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At our last assessment the provider failed to have effective governance systems to assess and monitor quality and safety. Checks on window restrictors had not identified shortfalls so that action could be taken to ensure safety. Following our last assessment the provider completed an action plan and told us they would take action to check every window to repair or replace all window restrictors where needed. They also said they would inform staff not to tamper with any of the restrictors. The provider told us this action would be taken and completed by the 30 June 2026. They also told us some of this work to repair and replace window restrictors was already completed immediately following our last assessment. However, we found this action had not been completed in full which meant some window restrictors were still not being used safely. This placed people at risk of harm.

Health and safety checks had been completed in June 2026 and recorded that all window restrictors had been checked and were ‘robust’ and ‘unable to be removed’. During our assessment we found some window restrictors had been tampered with and staff had opened the windows wide. This placed people at risk of harm. We also found some windows did not have a restrictor fitted which had not been recorded in the health and safety check. The registered manager said they would remove keys from the restrictors to prevent staff from opening them.

The registered manager completed a walk around the service to check the environment. They recorded that staff were repeatedly removing window restrictors. The provider failed to evaluate their systems and make improvements to make sure staff understood safe working systems. This meant people were at increased risk of harm.

The provider told us they had not visited the service as often as they would usually and gave assurances they would address the shortfalls.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.