Byrnhill Grove Registered Care 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated 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 provider was in breach of the legal regulation relating to good governance.​

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.

The provider had a shared vision, strategy and culture. The provider had a clear aim of providing a caring, person-centred service which promoted people’s rights and preferences. These values were stated in the staff handbook, which stated ‘Our Values are at the heart of our organisation and at the heart of our brand and act as the backbone for delivering a great service to the people we provide care and support to.’ Our observations whilst at the service as well as discussions with the management team and staff reflected this ethos.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. There was a management structure with senior staff, manager, area manager and the nominated individual. All were actively involved in the service. Staff were positive about the management team and discussions with them showed they knew people and staff individually. A new manager had been in post for several months and had submitted an application to register with the CQC. A person said of the manager, “She’s good. I can go to her and she can fix it or make it better for me.” An external professional told us, “The care home manager is excellent and works well with us. She has improved the service significantly since she started.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The manager told us they had an open-door policy and encouraged people, family members and staff to speak up freely. Staff said they felt able to raise anything with the management team and felt they would be listened to. Care staff were very positive about working at Byrnhill Grove and would recommend it as a good place to work. People and family members as well as external professionals felt able to raise anything with the manager and were confident action would be taken. There was regular engagement with people and their family members.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt supported and valued by the management team. All staff were positive about working at Byrnhill Grove and felt they were treated with respect. The management team valued diversity and ensured best practice guidelines were followed. The provider had a policy to support staff to work flexibly around any personal circumstances.

The provider’s systems of accountability or good governance had not always been followed and had failed to ensure people received safe care. Systems had not ensured that all information about risk management was documented and all necessary action taken to mitigate the risk. This is further detailed in the safe section of this report. Audits and management oversight had not identified issues we found with matters recorded in daily notes, a failure to implement some external professional guidance and responding to incidents and safeguarding concerns. A person was funded for some individual time, however there was no record of this being provided. Following the inspection, new systems were introduced to ensure daily care notes completed by care staff were promptly reviewed by a senior staff member, meaning any necessary actions could be taken and to record the 1 to 1 time provided.

As part of the inspection, we discussed the regulated activities and conditions of registration for Byrnhill Grove which the management team had not been fully aware of. They confirmed they would be following their registration conditions in future and would not be providing a personal care service for people in the adjacent flats as they had done on one occasion in 2025. Providers are required to notify CQC of various events within registered services. These are called notifications. Following the inspection the manager retrospectively submitted missing notifications to the CQC.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management team expressed an open, positive attitude to receiving support and understood how and where they could access this. The provider considered how they could enable people to live a good, ordinary life as part of their local community. They had developed links with local community organisations including schools, activities and religious organisations. The service had an accessible minibus which was used to attend local community events and activities.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. These included regular training sessions, meetings and supervision for managers and staff. The management team were open to feedback provided during our site visits and committed to making the necessary improvements. A comprehensive action plan had been developed to document and monitor improvements. The manager reviewed reports from other providers and used these to identify improvements such as the need to include additional risk assessments and information in care plans and was working to implement this. The provider had systems in place to help ensure any lessons learnt from ‘sister’ services were implemented across all their services.