CQC report explained · a nursing home
What the CQC found at Bybrook House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Bybrook House Nursing Home was rated Good; inspectors found safe care and strong leadership, with a small medicines storage issue corrected during the visit.
This was an unannounced inspection on 12 April 2021. One inspector visited the home, while another reviewed documents and feedback. Inspectors also spoke with people, staff, the manager, relatives and a health and social care professional.
The home was rated Good for Safe and Well-led. People told inspectors they felt safe, medicines were given as prescribed, staffing was sufficient, and infection control measures were in place. The home was clean and staff used protective equipment correctly.
Inspectors found that staff knew people well and supported person-centred care. The manager showed strong leadership, and audits, feedback and improvement work were being used to monitor the service.
This was not a full inspection of all five areas. Because of the pandemic, the planned comprehensive inspection was changed to cover Safe and Well-led. The previous overall rating was also Good, from 14 November 2017.
People felt safe
People and relatives said they felt safe and were confident that concerns would be addressed.
“People told us they felt safe within the home. Relatives had no concerns about their family member's safety.” from the report
Reliable staffing
Inspectors found enough staff, timely responses to call bells and a stable team with limited agency use.
“There was an established staff team, who knew people well.” from the report
Infection control
The home followed COVID-19 guidance, was clean, and staff used protective equipment correctly.
“Robust systems were in place to minimise the risk of infection and its transmission.” from the report
Strong leadership
The manager worked alongside staff and used audits, feedback and improvement work to monitor the service.
“The registered manager was experienced and demonstrated strong leadership.” from the report
Person-centred care
Staff knew people well and supported their choices, routines and quality of life.
“People received a person-centred service, which encouraged key values of choice, independence and quality of life.” from the report
Medicine stock checks
minorThe system for monitoring medicines in stock had previously lapsed and had been reinstated by the inspection.
“Staff had reinstated their system to monitor all medicines in stock, as this had lapsed.” from the report
- 01How do you now check that medicines are stored at the correct temperature and in the correct place?
- 02How often are medicine stock levels checked, and what happens if the checks are missed?
- 03How do you make sure there are enough familiar staff on duty when people are off sick or on leave?
- 04How will you assess and review my relative's individual risks, such as moving safely or managing health conditions?
- 05What activities, family contact and visiting arrangements are currently available?
This was a focused inspection of Safe and Well-led only; the planned comprehensive inspection was not completed because of the pandemic, so Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 7 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2017
Rated Good overall; inspectors found kind, responsive care, but the Effective rating was Requires Improvement because pressure mattresses and repositioning were not always managed correctly.
Inspectors made an unannounced visit on 23 and 31 August 2017. They spoke with people living in the home, relatives and staff. They observed care and meals, and checked care records, medicines, staffing and management records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were rated Good. Medicines management had improved since the previous inspection, and people generally felt safe and well cared for.
The Effective rating was Requires Improvement. Some pressure-relieving mattresses were set incorrectly, and some people were not repositioned at the times recorded in their care plans. Inspectors said this could increase the risk of skin damage, although no one had a pressure ulcer or skin breakdown at the time.
Improved medicines management
Inspectors found that medicines were stored securely, given when needed and recorded accurately. This addressed problems found at the previous inspection.
“There were daily stock check and audit of medicine administering records ensuring they had been completed accurately.” from the report
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed staff supporting people calmly, respectfully and with attention to privacy.
“Staff interacted with people in a kind, respectful and quiet way and spoke with people in a calming and friendly way.” from the report
Personalised support
Care plans included people's routines, preferences, health needs and life history. People were involved in reviewing their care.
“Care plans included information specific to the person about their needs and life history.” from the report
Activities and family contact
People could choose from activities such as gardening, pottery, exercise and quizzes. Visitors were welcomed without restrictions.
“People told us there were no restrictions on having visitors.” from the report
Pressure mattress settings
needs fixingSome pressure-relieving mattresses were set at the wrong level for the person using them. This could increase the risk of skin breakdown.
“There were a number where the setting was incorrect.” from the report
Repositioning records and care
seriousSome people were not repositioned at the intervals recorded in their care plans. Inspectors said this could increase the risk of pressure ulcers.
“There was inconsistent re-positioning of some people which did not meet the assessed time interval for them to be re-positioned.” from the report
Training for specific health conditions
minorInspectors found that staff training did not include some conditions affecting people in the home, including diabetes, Parkinson's disease and stroke.
“There was no training specific to health conditions such as diabetes, Parkinson's disease and stroke.” from the report
- 01How do you check that each pressure-relieving mattress is set correctly for the person using it?
- 02How do you make sure repositioning happens at the times set out in each person's care plan?
- 03What action was taken after inspectors found incorrect mattress settings and missed repositioning times?
- 04What training do staff receive about diabetes, Parkinson's disease and stroke?
- 05How have the home's quality checks changed so these problems are identified sooner?
This was an unannounced inspection covering all five CQC areas and included observations, discussions with people, relatives and staff, and checks of care and management records. This explanation was written from the published report of 14 November 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bybrook House Nursing Home
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- May 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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