CQC report explained · a residential care home
What the CQC found at Byron Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staff understood safeguarding, medicines systems had improved, and there were enough staff who knew the people they supported. Inspectors had some concerns about the cleanliness of the premises and one care plan was not up to date.
- Effective?
- Good
- Staff had relevant training, supervision and competency checks. People were supported with healthcare, food, activities, communication and decisions about their care.
- Caring?
- Good
- Inspectors observed kind and compassionate care. Staff respected people's privacy and dignity, listened to them and supported them to make choices.
- Responsive?
- Good
- People had personalised care plans and access to activities based on their preferences and goals. Staff supported communication, complaints, advocacy and community involvement.
- Well-led?
- Requires improvement
- There was no registered manager at the time of inspection, which limited the rating. Management had improved the service, but systems needed more time to become fully reliable.
What inspectors found, September 2021
Byron Court was rated Good overall, but well-led was Requires Improvement because there was no registered manager and cleanliness needed attention.
This was an unannounced, planned inspection. Inspectors visited the home, spoke with people, staff and families, and checked care records, medicines, recruitment, training and management records.
Inspectors found that people were generally safe and received kind, person-centred care. Staff understood people's needs, supported choice and independence, and helped people take part in activities and community life.
The home was rated Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because a registered manager was not in post and the improved management systems still needed time to become fully established.
The overall Good rating means the home met the required standards overall, but families should pay particular attention to the home's leadership, cleanliness and how improvements are being maintained.
Person-centred support
Staff understood people's individual needs and supported their choices, goals and preferred routines.
“We observed people receiving care that was genuinely person centred.” from the report
Choice and independence
People were supported to make decisions, manage risks positively, prepare food and take part in activities they chose.
“People were supported to be independent and had control over their own lives.” from the report
Improvement since the last inspection
The home had addressed the previous concerns about person-centred care, dignity, consent, safe care, staffing and governance.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Staff training and support
Staff received relevant training, induction, supervision and competency checks to support safe and effective care.
“Managers provided an induction programme for any new or temporary staff.” from the report
Cleanliness of the premises
needs fixingFamilies told inspectors that the environment could be cleaner. One person's room needed more prompting and support to maintain cleanliness.
“All families spoken with during the inspection felt the environment could be cleaner” from the report
No registered manager
needs fixingThere was no registered manager during the inspection. A new manager had started and was beginning the registration process, but this limited the well-led rating.
“There was no registered manager in post at the time of inspection.” from the report
Management systems still embedding
needs fixingGovernance processes had been reviewed, but inspectors said they needed more time to show that they could consistently identify and address problems.
“These required time to embed into the service to ensure they were robust to continue to identify failings and drive positive change.” from the report
One care plan was out of date
minorOne person's care plan did not contain updated information about their current needs. Staff knew how to support the person, and the provider was waiting for clarification from professionals.
“For one person their care plan did not contain updated information relating to their current needs.” from the report
- 01Has a registered manager now been appointed and registered with the CQC?
- 02What daily checks are now used to monitor cleanliness, and how are problems followed up?
- 03How do you make sure every care plan is updated promptly when a person's needs change?
- 04How do you check that the new governance systems continue to identify and fix problems?
- 05How are families kept informed about changes in a person's health, care or appointments?
This was a planned inspection covering all five key questions, with specific attention to the Right support, right care, right culture principles and infection prevention and control. This explanation was written from the published report of 11 September 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, December 2020
Byron Court was inspected but not rated; inspectors were assured about infection prevention and control, with resources signposted to develop the approach.
This was an announced, targeted inspection on 7 December 2020. It checked infection prevention and control during a coronavirus outbreak response.
Inspectors were assured that the home was managing visitors, shielding, social distancing, admissions, personal protective equipment and testing safely.
The home had a communal area for people who had tested positive for COVID-19 and did not want to stay in their rooms. Staff were tested weekly, and people living there were tested every 28 days.
The home was inspected but not rated. This means the visit did not give a Good, Requires improvement or Inadequate rating.
A separate communal area
The home had designated a communal area for people who had tested positive for COVID-19 and did not want to remain in their rooms.
“A communal area had been designated by the provider for people who had tested positive for COVID-19 and did not wish to remain in their rooms.” from the report
Regular testing
Staff testing took place weekly, while people living at the home were tested every 28 days. The home also checked that agency staff did not work elsewhere.
“Weekly testing of staff was completed, and those living at the home were tested on a 28 day cycle.” from the report
Infection control assurances
Inspectors were assured about the home's arrangements for visitors, social distancing, admissions, personal protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Approach needed further development
minorInspectors signposted resources to help the home develop its infection prevention and control approach. The report does not specify what further development was needed.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What resources were signposted to the home to develop its infection prevention and control approach, and what has changed since the inspection?
- 02How often are staff and residents tested now?
- 03How do you check that agency staff do not work elsewhere?
- 04How are visitors, personal protective equipment and social distancing managed now?
- 05How would people who test positive be supported if they do not want to stay in their rooms?
This was a targeted inspection of infection prevention and control during a coronavirus outbreak response; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 19 December 2020 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 Byron Court
4 rated inspections over 6 years: the service has held its Good rating throughout.
- September 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2020Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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