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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

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 detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. All windows were now fitted with window restrictors. The registered manager had taken action to make sure staff were not able to tamper with any restrictors and open windows wider than recommended in safety guidance.

Action had been taken to replace flooring in 2 areas of the service which reduced risks of trips and falls. Further improvement had been made by re-decorating these areas and other areas of the service. During our assessment, further planned work was being completed to make improvements to the building for fire safety. This was in response to fire risk assessment findings and recommendations. People said staff informed them of the works and kept them updated with progress.

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 assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean throughout and people told us staff regularly cleaned their rooms. Flooring had been replaced in 2 areas which meant staff could now thoroughly clean those rooms.

Regular checks were being completed to check for cleanliness which included audits of mattresses. The providers most recent check identified the need for 2 replacement mattresses which had been ordered. Staff were monitoring for cleanliness daily which meant risks of cross infections were reduced.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People said they were happy with the support they had from nurses to manage their medicines. Medicines were being managed safely, and people had their medicines as prescribed. Medicines administration records (MAR) did not have any gaps in recording, and any handwritten entries had been signed by 2 members of staff. This additional check for handwritten entries reduces the risk of transcribing errors.

Medicines were being stored safely with daily checks completed to monitor temperatures. For medicines needing additional storage checks staff were now checking weekly. This additional check was recorded and stock we checked matched written records.

Some people had been prescribed ‘as required’ medicines. An ‘as required’ protocol was written to give staff extra guidance for administering this type of medicine. We found 2 protocols did not have clear dosing instructions. The registered manager took action to address this during our assessment.

Staff were trained to administer medicines and had their competence assessed.