Byron Court 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

At our last inspection the provider was in breach of regulation in relation to safe care and treatment. We saw during this inspection improvements had been made and the provider was no longer in breach of regulation.

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 did mostly have a proactive and positive culture of safety based on openness and honesty. However, some safety concerns were not always embedded. Lessons were not always learnt to continually identify and embed good practice. For example, on day 1 of our inspection we found handheld devices with people’s personal details unlocked and unattended in the lounge. We made the provider aware of this straight away and saw from looking at team meetings this was an issue which had happened before, which meant learning was not always being implemented. The provider has since addressed this.

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. We saw example of where the provider worked closely with hospital discharge teams to ensure people had the correct information recorded about them to enable staff to support them safely. We also saw instances were discharges were challenged due to a lack of clear information from the discharging teams.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. There was a safeguarding policy and procedure in place. All staff had been trained in safeguarding and were able to describe to us the correct course of action they would take if they felt someone was being harmed or abused.

The provider did mostly work well with people to understand and manage risks. Staff always provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the recording of some information in risk assessments lacked detail in places. For example, 1 person had a mitigation in place around nutrition which was to offer them alternative meals if they were to decline any meals. We saw on at least 3 occasions the person had declined to eat their meal, however diary records did not evidence staff had offered alternatives in line with their risk assessment. We checked and saw this person had been given meals, and they had not lost weight. However, staff had not recorded these processes correctly. We highlighted this at the time to the registered manager who took immediate action to address this.

The provider did mostly work well with people to understand and manage risks. Staff always provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, the recording of some information in risk assessments lacked detail in places. For example, 1 person had a mitigation in place around nutrition which was to offer them alternative meals if they were to decline any meals. We saw on at least 3 occasions the person had declined to eat their meal, however diary records did not evidence staff had offered alternatives in line with their risk assessment. We checked and saw this person had been given meals, and they had not lost weight. However, staff had not recorded these processes correctly. We highlighted this at the time to the registered manager who took immediate action to address this.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Rotas showed there was enough staff in the home to provide safe care. Agency cover was needed occasionally, and all agency staff were provided with an in-depth induction process. Training statistics were above 90% for all subjects, and staff were recruited, selected and vetted safely.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Some parts of the home were not clean, such as doorways and some floors. We also observed a small batch of towels in a bathroom on top of a bin which could cause cross contamination. We raised this straight away and these observations were acted upon before we left the home. The registered manager also introduced a new daily walkaround tool, to ensure instances of potential IPC concerns were highlighted and dealt with straight away. The rest of the home was clean and tidy. There was a home improvement plan in place which had identified the need for some redecoration to take place.

The provider now made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff now involved people in planning, including when changes happened. We observed since our last inspection the process around recording medicines had been improved. People were administered time specific medication at the correct times. Each person had a medicines profile displaying a recent photograph. People’s allergies were recorded. Body maps were in place for the application of creams and patches and evidence of patch rotation in line with manufacturer’s instructions was seen. The administration and application of creams, patches, food supplements and thickener was recorded on people’s medication administration records (MARs). MARs were signed to evidence administration of prescribed medicines. Handwritten entries were checked and signed by 2 staff. PRN (as required) protocols contained sufficient guidance for safe administration. Administration records for the use of PRN medicines were maintained observed a person’s records for use of lorazepam and showed irregular use as staff found distraction techniques effective. People underwent regular medication reviews with their GP. Controlled drugs (CDs) were stored securely and a CD registered was in place. The register was filled in correctly following administration.