Byrnhill Grove Registered Care 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.

This is the first assessment for this service. This key question has been rated 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 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had procedures which would ensure appropriate action would be taken to investigate and learn from incidents, but these were not consistently followed. During the week prior to the inspection, staff had documented 2 incidents within daily notes but had not taken the subsequent action to log these as incidents under the provider’s procedures. This meant actions to formally investigate and reduce the likelihood of future events or mitigate risk were not undertaken. The manager introduced new procedures to review all daily records of care so that adverse incidents would be promptly identified and action taken as required. Other safety events such as accidents had been recorded and appropriate action had been taken to understand risk factors and take action to reduce the risk of future similar events. Family members and staff confirmed they were updated following accidents and incidents. The provider fulfilled their duty of candour responsibilities.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Systems were in place to ensure continuity of care when people commenced living at Byrnhill Grove and there was involvement of the person, family members and external health or social care professionals. The manager undertook a preadmission assessment to confirm the service was able to meet the person’s needs and to ensure care plans and any required equipment was in place. Where a person needed to be admitted to hospital or transferred to another service, relevant information about their medicines, level of emergency health support and health and care needs were provided.

Although the manager and staff were able to describe their safeguarding responsibilities and actions they would take if they had a safeguarding concern, they had not identified 2 incidents between people as abuse. A person sometimes behaved in a way that was emotionally and physically intimidating to other people. Although staff were documenting this within daily care notes, more comprehensive records detailing what happened before, during and following incidents were not being recorded. This meant action to identify possible reasons for the behaviours and reduce the risk of these repeating was not taking place. Where these incidents had occurred, the provider’s safeguarding procedures had not been followed and action taken to reduce the likelihood of future similar incidents. CQC and the local authority safeguarding team had not been notified in some instances. The management team took prompt action, including submitting retrospective notifications and safeguarding alerts.

Feedback from people and family members confirmed they felt safe. A person said, “Yes. It’s very secure and there’s always someone around.” Another person told us, “Yes. I’ve no reason not to [feel safe].”

People did not receive consistent support from staff to manage risks associated with their health and wellbeing. We found some aspects of care plans were incomplete and records of care provided showed some actions to manage risk were not being undertaken. For example, one person should have had daily support to complete physiotherapy exercises daily prescribed by a health professional. There was no record of this within the care plan or in the person’s mobility risk assessment. Care staff and the manager were unaware of the health professional’s exercise plan and confirmed this was not occurring. This meant the person was at risk of their mobility deteriorating, reducing independence increasing their care needs. For another person, alternatives had not been considered where existing equipment had been proven not to adequately manage this person’s risk of falls. This meant they remained at risk of falling due to staff not being promptly alerted to their moving around their bedroom.

Some health risks were also not being fully managed. For example, staff and the management team had not noted a change in a person’s continence habits, which meant no action was taken and could have resulted in a medical episode the person subsequently experienced. Staff had appropriately sought medical advice for another person to manage a medical risk, however, the guidance had not been followed to seek further medical support if the condition continued for longer than a week. The failure to ensure prompt action was taken when people’s health and care risks changed meant people were placed at risk of not having their risks managed and reduced.

The manager took prompt action to ensure information in daily records completed by care staff was reviewed by a senior staff member and any necessary action taken. The management team also stated they were in the process of reviewing all care plans to ensure information was correct and consistent. Equipment to help manage other identified risks, such as pressure relieving equipment was seen in use where required. Staff and training records confirmed staff had received training to use equipment safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Risks relating to the living environment had been assessed and action taken where needed to manage risks. Bedrooms were individualised and contained people’s personal belongings. Communal facilities were appropriate for the size and needs of the people living at Byrnhill Grove and were well maintained and pleasant. Where equipment was required, such as for moving and skin integrity, we saw this used correctly. Records showed equipment was regularly serviced and care staff told us they had access to all equipment they required.

Staff had received training and effective support, supervision and development. They worked together well to provide safe care that generally met people’s individual needs. Staff identified that they were often busy especially in the morning and could miss their morning break to ensure all work was completed. People reported staff were busy at times. One person said, “There’s not enough. They’re always busy.” External professionals told us, “There may not be enough staff, or indeed the layout of the home doesn’t lend itself to allow carers to be able to monitor residents as closely as other homes we work with” and “There doesn’t seem to be the level of staffing my client needs to support daily activities and support some of the recommendations in their positive behaviour support plan.

There were appropriate pre-employment procedures in place. Most training was up to date and covered topics relevant to the service. A formal process was in place to support staff with regular staff meetings, supervision and appraisals. A family member said of the staff, “That’s the nice thing, the regular staff. It’s a small home and the staff have been here a long time and they know [relative].”

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 home appeared clean throughout with no unpleasant odours. Housekeeping staff told us about routines to ensure all areas were regularly cleaned. Staff received food hygiene and infection control training and confirmed the availability of Personal Protective Equipment (gloves and aprons) and we saw them using these appropriately. A family member told us, “They [staff] wear gloves and aprons.” The management team understood the actions they should take should there be an infectious disease outbreak at the home. The home had been awarded 5 stars (the maximum) following a recent environmental health inspection for food hygiene.

The provider made sure that medicines were safe and met people’s needs capacities and preferences. Medicines were stored securely and administered safely, however, systems to ensure this was always at a safe temperature could not be guaranteed. The manager took prompt action to ensure medicines were stored at the appropriate temperature. There was a risk that some topical creams could be used beyond their ‘safe to use once opened’ dates. Weekly and monthly medicines audits and staff had not identified these concerns. However, the manager took prompt action to ensure safe systems were in place. Staff responsible for the administration of medicines received appropriate training and their competency had been assessed. People were happy with the way their medicines were managed. One person said, “I have painkillers when necessary.”