CQC report explained · a residential care home
What the CQC found at Byron House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks had been assessed and care plans gave staff guidance on keeping people safe. Inspectors also found enough staff, safe recruitment, suitable medicines systems and effective infection controls.
- Effective?
- Good
- People's needs and choices were assessed and reviewed. Staff received training and support, and worked with health and social care professionals. Most people enjoyed the food and had plenty of choice, although two people did not enjoy it.
- Caring?
- Good
- People said staff treated them well, respected their privacy and understood their individual needs. People were involved in decisions about their care where they wanted to be.
- Responsive?
- Good
- Care plans were personalised and reviewed at least monthly or when people's needs changed. People could raise concerns, maintain relationships and take part in activities that suited them.
- Well-led?
- Good
- The registered manager had strengthened quality checks and acted on shortfalls. Staff and people said communication was good, and inspectors found the home worked with other agencies.
What inspectors found, October 2021
Rated Good; inspectors found safe, kind and well-organised care, with improvements since the previous inspection.
The inspection was unannounced and took place on 10 August 2021. Two inspectors spoke with six people, five staff and the registered manager. They reviewed care plans, medicines records, staff files, training information and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable recruitment checks, clear care records, staff training and support, and systems to manage medicines and infection risks.
The home had previously been rated Requires Improvement, with several breaches of regulations. Inspectors found that the provider had made the required improvements and was no longer in breach.
Risks were managed
Risk assessments were in place and staff understood the safety guidance for individuals. Inspectors also saw staff respond quickly during an emergency evacuation.
“Risks to people's health, safety and welfare had been identified and assessed.” from the report
Respectful care
People said staff treated them well and respected their privacy, independence and individual choices.
“Staff had a clear understanding of people's diverse needs and preferences and demonstrated a caring and considerate approach when interacting with people.” from the report
Personalised support
Care plans reflected people's wishes and gave staff clear instructions about how to provide support.
“Care plans were detailed and gave clear guidance for staff about how to provide person-centred support for people.” from the report
Improved management
The home had strengthened its quality monitoring since the previous inspection. The manager used audits to identify and address shortfalls.
“Since the registered manager had been in post quality assurance systems had been embedded and strengthened.” from the report
Food preferences
minorMost people enjoyed the food and had plenty of choice, but two people said they did not enjoy the food and preferred takeaway food when possible.
“Two people said they did not enjoy the food provided and preferred to eat take away food when they could.” from the report
Outside space
minorThe outside area was tidy, but the manager said the home was considering ways to make it more inviting.
“Although the outside space was tidy, the registered manager said they were looking at options to make the outside space more inviting.” from the report
- 01What changes have been made to the food since two people said they did not enjoy it?
- 02What improvements have been made to make the outside space more inviting?
- 03How often are care plans and risk assessments reviewed now, and what happens when people's needs change?
- 04How are medicines records checked and any errors or missing information followed up?
- 05How does the home make sure the improvements found at this inspection have been maintained?
This was an unannounced planned inspection covering all five CQC key questions, including infection prevention and control under Safe. This explanation was written from the published report of 6 October 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 2019
Rated Requires Improvement, with unsafe care planning, poor consent checks and inadequate leadership creating risks for people.
This was an unannounced inspection over two days, followed by a visit to check improvements. Inspectors spoke with six people and four staff. They reviewed care, medicines, staff and management records.
The home had enough staff, safe recruitment and generally safe medicines systems. People said they felt safe, and staff were described as kind by many people. However, risk assessments were missing or lacked important guidance, and one person with significant weight loss had not been referred to a GP until inspectors raised it.
Inspectors found incomplete mental capacity assessments and missing best-interest decisions. People were also restricted from using a kitchen area freely. Care plans were not consistently reviewed, and formal audits were not being done.
The overall rating fell from Good to Requires Improvement. Safe, Effective, Caring and Responsive were all rated Requires Improvement. Well-led was rated Inadequate because leadership, record-keeping and quality checks were not effective. The provider was asked for an action plan, but the follow-up visit found that most actions were still outstanding.
Enough staff
People and staff said staffing levels were sufficient, and rotas supported this. Recruitment checks included references and Disclosure and Barring Service checks.
“People and staff told us there were enough staff to support them and staff rotas confirmed this.” from the report
Medicines
Medicines were given on time and records were checked through regular audits. Staff who gave medicines had training and competency checks.
“People told us staff supported them to take their medicine and medicines were given on time.” from the report
Feeling safe
People told inspectors they felt safe in the home. Staff had safeguarding training and knew how to report concerns.
“People told us they felt safe living at the service.” from the report
Supportive relationships
Inspectors saw positive interactions, and many people said staff were caring, friendly and knew them well.
“We observed positive interactions between staff and people during the inspection.” from the report
Healthcare access
Staff generally helped people arrange and attend healthcare appointments. Hospital passports were available for people.
“People had access to healthcare services to support their well-being.” from the report
Risk information was incomplete
seriousSome risk assessments were missing or did not explain how staff should keep people safe. At the follow-up visit, nearly all care plans were still held in the manager's office.
“Risk assessments were either not in place or did not contain enough detail to allow staff to care for people safely.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interest decisions were not completed properly. One person's possible deprivation of liberty had not been reviewed, and access to a kitchen was restricted.
“The failure to ensure mental capacity assessments and best interest decisions for people had been carried out was a breach of Regulation 11” from the report
Poor care plan oversight
seriousCare plans were not regularly evaluated, some were incomplete, and there were no formal audits of care plans. This meant the home could not reliably check that care remained suitable.
“The failure to ensure the service was effectively monitored was a breach of Regulation 17 of the Health and Social Care Act 2008” from the report
Health concern not followed up
seriousOne person had lost a very significant amount of weight but had not been referred to their GP until inspectors raised the issue.
“One person had lost a very significant amount of weight. This person had not been referred to their GP for investigation” from the report
Unsettled management
needs fixingThe home had been without a registered manager since January 2019 and staff described several management changes. The report linked this to weaknesses in support, governance and oversight.
“The lack of leadership and support within the home over previous months had impacted on the overall governance and oversight within the home.” from the report
Limited activities
minorActivities were available, but people gave mixed views and some thought there should be more. The report also noted restrictions on freely accessing drinks and food in the kitchen.
“People did have access to limited activities within the home.” from the report
- 01Have all residents' risk assessments now been completed, including risks such as self-harm and epilepsy, and can staff access them during shifts?
- 02How are mental capacity assessments and best-interest decisions completed and reviewed now?
- 03What has changed since the follow-up visit, when most care plans were still held in the manager's office?
- 04Does the home now have a registered manager, and how is management continuity being maintained?
- 05How can residents freely access food, drinks and the kitchen while keeping the area safe and clean?
This was an unannounced planned inspection covering all five CQC questions, with a follow-up visit on 09 October 2019 to check whether requested improvements had been made. This explanation was written from the published report of 24 December 2019 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 House
3 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.