Byron Lodge 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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safeguarding, infection prevention and control, people’s safe care and treatment and the way people’s medicines were managed safely.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Accidents and incidents were recorded on the provider’s electronic system but no trend or thematic analysis was carried out. Records of accidents and incidents were not followed up to identify learning and changes and improvements to practice. The registered manager recognised they had not always notified CQC of accidents and incidents in a timely manner. The provider had taken steps to make improvements to prioritisation of reporting and notification processes.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The provider used an electronic care planning system to record information and updates about people’s care and support. The management team were not confident key information about people’s care and support was recorded on the system in a timely manner. We saw examples where meeting notes recorded referrals to healthcare professionals had been made but this information had not been recorded as a professional note on the provider’s electronic system. This meant all information about people’s care and support could not be shared if they moved between services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how this could be achieved. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. 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. As a consequence, the registered manager and the staff team did not have access to a current safeguarding adults policy. The registered manager made us aware they had not had access to any policies or procedures since they had been in post. One person told us, “I am safe, [members of staff] are nice to me. I am fine now, since I came here.” A relative said, “I think [family member] has been safe here, since they came in. I think [member of staff] look after them well and I come to see [family member] quite a lot.”

We saw evidence the provider followed the principles of the Mental Capacity Act 2005 (MCA) to review people’s capacity and understanding around receiving care and support. However, the provider had completed assessments of people’s capacity but the risks identified in some people’s capacity assessments were not recorded in line with other areas of their care plan. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We reviewed records associated with people’s 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. 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. For example, there was no evidence about what had been done to reduce the risk for a person who was at risk of falls following a series of falls in their bedroom in a short timeframe. The person was also at high risk of pressure damage. Their care plan stated pressure care checks on their skin integrity should be completed every 2 hours but this was not always the case. Evidence from the care notes showed pressure care checks had only been completed twice in 7 hours. Another person had bedrails in place but there was no risk assessment in their care plan which meant the risks associated with the bedrails had not been identified, reviewed and mitigated. We spoke with a member of the clinical team and they explained the service will be using a ‘resident of the day’ to reviewing people’s care plans. We saw evidence of some care plans which had been reviewed but there were still a large number of care plans and risk assessments to be reviewed before everyone’s care plan would be completely updated. We were not assured there were resources and capacity in place to enable this to happen in timely way.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. There was no dedicated person responsible for maintenance and compliance checking in the care home. The care home received support from other services in the provider’s care group. As a result, there were some elements of regular compliance checks which had not been completed in line with expectations. This was recognised by the provider and had been included on their risk register. Safety and compliance checks carried out by external qualified and competent people had been completed and evidence was recorded on an electronic dashboard.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs. Members of staff were task-focussed and not deployed effectively. People were sat in communal lounges with minimal engagement and interaction from members of staff. For example, over lunch on a nursing unit members of staff were deployed serving food and the nurse was administering medications to people. As a consequence, there was limited availability of members staff to provide support to people if they needed it, particularly people who remained in their bedrooms or who were in their beds. One person told us, “Yes, I am safe here but sometimes I get annoyed with some of the temporary staff. They just do their jobs, they are not really carers. There seem to be a lot at the moment. I don’t know if that's because it’s the holidays.” The provider had safe systems in place to monitor and review the recruitment of new members of staff. A relative told us, “The carers are very good but communication is an issue, there is a language barrier with the agency staff. Sometimes [family member] can’t understand them and they can’t understand [family member]. There have been falls here and I feel I have to help as there is no one around. [Members of staff] tell me not to help them as it can hurt me too but it’s not good when there’s no one around.”

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. For example, a person’s bedding was dirty and stained with blood and there was debris in their bed. We raised this with a member of staff and the registered manager so their bedding could be changed or replaced. We saw evidence of damaged floors and staining in people’s en-suite bathrooms and communal bathrooms smelled damp. The registered manager recognised this and said they had raised this with the provider but no action had been taken. Personal protective equipment (PPE) was not readily accessible throughout the care home. Anti-bacterial hand foam dispensers throughout the care home were empty. The registered manager confirmed they carried out daily walkarounds and they acknowledged these were not as effective and in-depth as they could be. The issues around cleanliness and infection prevention and control identified by CQC inspectors had not been identified on any audits carried out by the registered manager or the provider and there was no evidence of action taken to make improvements.

The provider did not make sure management of medicines and treatments was safe and met people’s needs, capacities and preferences. We found out of date prescribed medicated cream in a person’s wardrobe. This medicated cream was paraffin-based and we were not assured there was an appropriate risk assessment in place for the person who was also a smoker. A recent medication audit had been completed by the provider’s regional clinical representative. Areas for improvement around controlled drugs prescribed ‘as and when’ (PRN) had been identified, however, actions for improvement had not been put into place. Where PRN protocols for other controlled drugs were in place there was poor recording of information about the effect and outcomes on the person following administration. Pain patch rotation charts were not updated accurately and associated body maps were not completed. Medication administration records for people who required prescribed creams were not completed accurately to reflect the required schedule of application. It was unclear if people had received their creams as prescribed. We were not assured there was appropriate clinical oversight of medications and the medication administration process in the care home.