CQC report explained · a nursing home
What the CQC found at Byron Lodge Care Home Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found risks, medicines, infection control, records and personalised care were not managed reliably.
This was an unannounced inspection on 29 and 31 March 2023. Inspectors spoke with people, relatives, staff and managers. They observed care and reviewed care records, medicines records, staff files and management records.
The home was not consistently safe or well managed. Risk assessments were incomplete, medicines were not always given as prescribed, some areas were not clean, and infection control practice was not always safe. Care plans and records did not always contain the information staff needed. Food, drinks and some care did not always match people's needs and preferences.
People and relatives said staff were kind, caring and friendly. There were enough staff overall, people could access health professionals, and activities took place. However, the overall rating remained Requires Improvement, meaning inspectors found limited assurance about safety and an increased risk that people could be harmed.
Kind staff
People and relatives spoke positively about staff, describing them as kind, caring, friendly and welcoming.
“Despite the feedback above, people and relatives told us staff were kind, caring and friendly.” from the report
Staffing and recruitment
The home had recruited staff safely and inspectors found suitable staffing levels overall. People usually knew the staff supporting them.
“There were suitable numbers of staff to provide the care and support people were assessed as needing.” from the report
Healthcare access
People were supported to see GPs and other healthcare professionals when needed. Emergency calls and referrals were made where appropriate.
“People had access to health services when they needed it.” from the report
Activities and social contact
Staff provided activities, including individual activities for people cared for in bed, helping reduce the risk of social isolation.
“We observed activities staff routinely engage with people who spent time in their bedrooms, which reduced the risk of social isolation.” from the report
Medicines
seriousSome medicines were not given according to prescribing instructions, and guidance for some medicines to be given when needed was incomplete.
“The provider has failed to manage medicines safely. This placed people at risk.” from the report
Infection control
seriousSome areas and equipment were not clean. Staff did not always use protective equipment safely when a person needed infection precautions.
“The provider had failed to manage, assess and control the risk of infection.” from the report
Food and drinks
seriousMeals, textures and drinks did not always reflect people's assessed needs or preferences. Records did not always show clearly what people had eaten or drunk.
“The provider had failed to meet the nutrition and hydration needs of some people living at the service.” from the report
Personalised care plans
seriousCare plans were sometimes late, incomplete or not based on people's health conditions and wishes. Staff therefore did not always have clear instructions for safe, individual care.
“The failure to design care and treatment to ensure people's preferences and needs are met was a breach of regulation 9” from the report
Quality checks and records
needs fixingAudits had not found several problems, and records were not always accurate or up to date. The provider also failed to notify CQC about DoLS applications and authorisations.
“Systems in place to audit the quality of the service continued not to be robust or sufficient to alert the provider of concerns and issues within the service.” from the report
- 01What has been done to make sure risk assessments cover pressure area care, moving and handling, epilepsy and emergency evacuation?
- 02How do you now check that medicines, including patches and medicines given when needed, are administered exactly as prescribed?
- 03How do you make sure staff use protective equipment correctly and that all areas and equipment are kept clean?
- 04How are dietary needs, food textures, drink targets and food and fluid records checked for each person?
- 05When will the new care planning and electronic records system be fully in use, and how will you ensure people's wishes and legal DoLS arrangements are recorded accurately?
This began as a focused inspection of Safe and Well-led, but was extended to all five key questions after inspectors found concerns about mental capacity, DoLS and care planning. This explanation was written from the published report of 7 June 2023 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, September 2020
Targeted inspection left the previous Requires Improvement rating unchanged; inspectors found people were generally safe and cared for kindly, but communication needed improvement.
This was a targeted inspection in August 2020 after concerns about people's safety and care. Inspectors visited on 3 August, spoke with 12 people and five staff, observed care, and checked care plans, risk assessments, staffing, training and management records.
Inspectors found that people were generally happy with the support. Care plans and risk assessments were complete and updated. Staff understood people's needs, there were enough staff to meet needs, and infection control arrangements were in place.
Some concerns were found about the tone used by some staff and how fully relatives were updated. This inspection did not give new ratings. The previous overall rating of Requires Improvement remained unchanged because this inspection only checked specific concerns, not the whole service.
Care planning
Care plans and risk assessments were complete, regularly reviewed and updated. Staff understood people's individual risks and support needs.
“Care plans were complete, regularly reviewed and updated.” from the report
Kind interactions
Inspectors observed staff being kind, attentive, encouraging and respectful when supporting people.
“Staff treated people with kindness, respect and compassion.” from the report
Safety arrangements
Staff had safeguarding training, understood how to report concerns, and used risk assessments to guide care. Infection control and protective equipment arrangements were also found to be in place.
“Staff had received safeguarding training. They understood their responsibilities in reporting safeguarding issues and to protect people from abuse.” from the report
Management checks
The provider and managers carried out regular audits. Where problems were found, action plans were created and checked when completed.
“The provider, registered and deputy managers completed regular audits on all areas of the service.” from the report
Staff communication
needs fixingOne person said some staff could be abrupt in their tone and manner. Inspectors raised this with the manager.
“However, one person told us they felt staff were occasionally "abrupt" when they spoke to them.” from the report
Information for relatives
needs fixingSome relatives felt communication from some staff could be better, including more useful information about how their family member was.
“some felt communication from some staff could be improved.” from the report
Staff vacancies
minorThe home was still recruiting to fill three vacancies. Inspectors said staffing levels were enough at the time and regular agency staff were used to cover sickness.
“Recruitment remained ongoing to fill three vacancies at the service.” from the report
- 01What have you done since the inspection to address concerns about some staff being abrupt?
- 02How will you make sure relatives receive fuller and more useful updates about their family member?
- 03How many of the three staff vacancies mentioned in the report have now been filled?
- 04What actions from the previous Requires Improvement inspection are still outstanding?
- 05When will the next comprehensive inspection assess all five key questions?
This was a targeted inspection of specific concerns within Safe and Well-led; the other questions were not assessed and the previous Requires Improvement ratings were not changed. This explanation was written from the published report of 23 September 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 Lodge Care Home Ltd
3 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2016
Registered with the Care Quality Commission on 23 December 2016.
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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91 live-in carers within about an hour of Medway
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Most charge £980 to £1,250 a week. 78 can care for a couple. 10 years' experience on average.
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