Byron Lodge 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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 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 management team confirmed the staff team did not have access to key information about the service and the provider. Members of staff were not aware of the provider’s vision for the organisations. Values did not drive staff meetings, instead only urgent items were discussed. The culture in the service was not based on trust and the local management team had limited confidence that accurate information was recorded in daily notes and care plans.

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 support the local management team to lead the service effectively and there had not been a stable management team in the service for 6 months. There was limited trust between the registered manager and the clinical team which had not been recognised or addressed by the provider. The provider’s information reporting system had not been used effectively to monitor and review performance, risk and quality improvement in the service.

People did not always feel they could speak up and their voice would be heard. There were no meetings where people who lived in the care home could speak up and suggest areas for improvement. There was confusion in the service about availability and access to organisational policies and procedures. The registered manager had not received key information from the provider therefore members of staff did not have access to policies about safeguarding and whistleblowing. The registered manager acknowledged they needed support from the provider and had not received this, but they did not feel confident in escalating it within the organisation.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There were no specific issues raised in relation to equality, diversity and inclusion within the service, however, members of staff did not have access to key organisational policies and procedures in place to promote workforce equality, diversity and inclusion. The systems in place to create an inclusive workforce were not fully utilised and staff meetings did not always foster a sense of belonging.

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. There was a lack of trust between the registered manager and members of the clinical care team linked to recording information, making referrals to local health and care service and completion of expected actions. For example, clinical governance meetings took place but key cases, where action had been taken, were not discussed and referral information was not recorded in the electronic care planning system. Therefore, referrals for people and their associated health outcomes were not monitored. The registered manager carried out daily walkarounds of the care environment but these had not been completed effectively and the issues and concerns identified by CQC were not known to the registered manager. Where daily walkaround checks had taken place, there was no evidence of analysis or follow up to ensure any identified actions had been completed. As a result of concerns raised about the service, the provider had completed quality reviews using its central information management system. However, prior to this, the system had not been used effectively to monitor and review performance, risk and quality improvement within the service. Specific areas for improvement had not been linked to an action plan for the registered manager to implement, therefore no action had been taken to make improvements. This had not been identified by the provider which resulted in a reduction in the quality of care and support within the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. There was limited engagement with local communities and community-based services. We did not see any evidence of proactive or positive relationships with the local community.

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. They did not actively contribute to safe, effective practice and research. We did not see evidence of a learning culture in the care home. There was limited support for the registered manager and the provider had not put support processes in place using skilled leaders from its other services, despite being aware of the lack of clinical leadership and consistent nursing presence in the service. A recent, reactive visit from the provider’s clinical quality lead had taken place but there was no immediate action plan in place to support continuous clinical improvement and clinical governance processes.