- Care home
Byron Lodge Care Home
Assessment report published 15 January 2026
Contents
Ratings
Our view of the service
Date of assessment: 11 December – 19 December 2025. We visited the service on 11 December 2025 and reviewed the care and support people received along with their care records and management information. Byron Lodge Care Home provides residential and nursing care to older people. Some people using the service were living with dementia. Byron Lodge Care Home can accommodate up to 61 people. On the day of inspection there were 45 people living in the service and 2 people were in hospital. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection. We carried out a focussed inspection of the service under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We looked at all of the quality statements in the Safe and Well-Led key questions because we had received concerns about the safety of people and the quality of care and support at the service.
The provider was in breach of legal regulation in relation to safeguarding, infection prevention and control, people’s safe care and treatment, the way people’s medicines were managed and governance of the service.
The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. People who lived in the care home told us they felt safe, however, there was confusion in the service about access to and availability of policies and procedures to keep people safe. We reviewed records associated with Deprivation of Liberty Safeguards (DoLS) and identified inconsistencies in how information was recorded. We were not assured the provider kept the Local Authority’s DoLS team up to date with all relevant information and changes associated with people and their DoLS paperwork. The provider did not work well with people to understand and manage risks. Members of staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. People’s care plans and risk assessments were not completed effectively. The provider did not always make sure there were enough qualified, skilled and experienced staff available to meet people’s need. Members of staff did not always work together well to provide safe care which met people’s individual needs. The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We saw evidence of poor infection control practices throughout the care environment. The provider did not make sure management of medicines and treatments was safe and met people’s needs, capacities and preferences.
The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.
This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
In instances where the Care Quality Commission have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
People's experience of this service
We spoke to people and their relatives as part of the inspection of the service. People were generally happy with the care and support they received but people did identify where improvements could be made. so they could have their ideas about improvements and developments taken into account. People told us they felt safe in the care home and they knew how to raise concerns if they had any. There were, however, concerns raised about availability of members of staff and consistency of staff teams. One relative told us, “I have a good relationship with a lot of the staff as well. I am concerned there isn’t enough staff. There are 2 or 3 carers on and when 1 goes for a break, and 2 carers are needed for 1 person then it doesn’t leave anyone else to look after other people. They need consistency on this unit. Sometimes they don’t have seniors to deal with things at night-time.” A person who lived in the care home told us, “There are definitely not enough staff. If you ask for help to go to the toilet, it varies how long you have to wait. It can be 10 or 15 minutes or I have waited up to 1 hour. It depends on what staff are on. You have to wait longer for the temporary staff. I ask the day staff to get me ready for bed before they leave their shift. If I wait for the night staff to be available, they come at 10pm or 11pm and this is too late for me.” Another person said, “I get what I need, I am quite independent and they let me do what I want. I ask for extra help if I need it. The staff are busy at times and you have to wait for them to come back.” A relative told us, “The staff do a great job but they could do with some extra staff. When I have seen how many there are, they could do with some more. There are some that have been here all the time and there are agency staff.” When we asked people what could be improved in the care home, one person told us, “The regular staff are good and I think it would be better if there were more of them. The temporary staff just see it as a job and are not as good. Some are in better moods than others, some are more easy-going. I used to have a shower every morning at home, when I got up. I was told when I came here, I could have a shower every other day. I would prefer a shower every day but I understood from the beginning that isn’t possible.”
People told us they knew who the registered manager was and they felt confident talking to any member of staff. One person said, “[Registered manager] was here yesterday or the day before. They have popped in a few times and they are very nice, so nice. I have talked to them a lot of times, they are down to earth and willing to help.” Another person told us, “I have no idea who the [registered] manager is. I could pick anyone to talk to.”