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Byron House Requires improvement

We are carrying out a review of quality at Byron House. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 24 December 2019

About the service

Byron House is a care home providing accommodation and personal care for up to 23 younger adults living with a mental health condition. At the time of inspection, there were 21 people living at the home.

People’s experience of using this service and what we found

During the inspection we found the registered provider was in breach of regulations in relation to safe care and treatment; need for consent; and good governance.

The service had been without a registered manager since 2 January 2019. A new acting manager was appointed in early January 2019 and held this role for a period of months before returning to their substantive role. Another manager was then appointed and came into post on 5 September 2019.

Work was required to address issues identified within people’s individual risk assessments to ensure they included how staff should care for people to keep them safe.

People had been referred to healthcare professionals to support their well-being. However, one person had lost a considerable amount of weight and they had not been referred to their GP for investigation.

Some people’s care plans included incomplete or incorrect mental capacity assessments. People were restricted in their access to a resident’s kitchen area.

Not all people’s care plans had been evaluated regularly to monitor people’s health and well-being and others were only partially completed. No formal audits had been carried out regarding people’s care plans. The regional manager told us care plans were in the process of being re-written. They also shared with us this was a task which had been included on the home’s action plan.

Staffing levels, recruitment and people’s medicines were managed safely. Staff had received training to support them in their role. However, refresher training for some staff was out of date. We have made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice.

People told us they felt safe living at the service. Staff were confident in their ability to identify and raise any safeguarding issues.

People were supported where necessary, by staff to access the community. People did have access to limited activities within the home.

The regional manager acknowledged work was required to address issues which had been identified prior to, and during the inspection. They had created an action plan for the home, the progress of which was monitored on a weekly basis.

Following the inspection, we sent the provider a letter which included our concerns which we had identified during the inspection. The provider responded to our letter, including a list of actions they would take to address our concerns. Following receipt of this letter, we carried out a follow-up visit to the service on 9 October 2019, to see if those improvements had been made. We identified minimal action had been taken, resulting in the majority of actions remaining outstanding.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 4 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified three breaches in relation to safe care and treatment, need for consent and quality assurance processes at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will ask the provider to provide an action plan of how they plan to improve their rating to at least good.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 24 December 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 24 December 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 24 December 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 24 December 2019

The service was not always responsive.

Details are in our responsive findings below.



Updated 24 December 2019

The service was not well-led.

Details are in our well-led findings below.