Updated 10 June 2025
Date of Assessment: 17 June to 2 July 2025. The service is a residential care home providing care and accommodation to older people including those living with dementia.
This assessment was prompted due to Byrnhill Grove not yet having been inspected since registration under this provider, and concerns received by the Care Quality Commission (CQC). We found there was no evidence to support these concerns.
The provider was in breach of the legal regulation relating to good governance.
Where we identified areas for improvement the management team took prompt action to make the necessary changes. This included ensuring all risks were understood by staff and systems were in place to reduce these as far as possible. Changes included a senior staff member reviewing all records of care provided for people, to identify any areas for further action or which required reporting to external agencies. The management team had been unaware of some of their legal conditions relating to the registration of the service. Once fully aware of these, they confirmed they would not be providing services outside their registration.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive. Staff felt supported to give feedback and were treated equally, free from bullying and harassment.
People told us they felt safe. The facilities and equipment met people’s needs, were clean and well-maintained and any risks reduced. Staff managed medicines well. Although staff had the right skills, qualifications and experience, there were not always enough staff to meet all needs. Managers made sure staff received training and regular appraisals.
People were involved in assessments of their needs. Care was based on latest evidence and good practice. People had enough to eat and drink to stay healthy. There was a range of activities, providing mental and physical stimulation. People’s health needs were known and monitored to support healthy living. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to take decisions in people’s best interests where they did not have capacity.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported to ensure their preferences were known and met. People had choice in their care and were encouraged to maintain relationships with family and friends. The provider supported staff wellbeing.
The provider actively sought feedback from people and acted upon this. People were consulted and involved in decisions about Byrnhill Grove. People knew how to give feedback and were confident the provider took it seriously and acted on it. People were involved in planning their care.
The service was supporting a person living with a learning disability or autism However, they were not ensuring the principles of right support, right care, right culture were being fully followed.
We have asked the provider for an action plan in response to the concerns found at this assessment.