CQC report explained · a nursing home
What the CQC found at Byron Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Byron Lodge Care Home was rated Requires Improvement; inspectors found medicine safety and leadership systems were not reliable enough.
This was an unannounced focused inspection on 12 April 2023. Inspectors looked at Safe and Well-led because of concerns about medicines, infection control and leadership. They spoke with people, relatives and staff, observed care and reviewed records.
People did not always receive medicines as prescribed. One person went without prescribed medicines for five days, and medicine records were not always accurate. The home was generally clean, but some areas needed deep cleaning and better organisation.
Checks and audits had identified problems, but these were not always fixed promptly. Inspectors also found that some people did not receive fully person-centred care, including a poor meal-time experience. The new manager had started making changes, but these systems needed to become reliable in day-to-day practice.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected and their previous ratings were used when calculating the overall rating.
Safeguarding arrangements
The home had systems for reporting and monitoring safeguarding concerns. Staff understood the safeguarding procedure.
“Staff we spoke with told us they received training in safeguarding and could explain the providers safeguarding procedure.” from the report
Mental capacity practice
Inspectors found that the home was working within the Mental Capacity Act principles. The required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
New manager
People, relatives and staff viewed the new manager positively. The manager had already reduced the use of agency staff by encouraging the home's own staff to cover extra hours.
“People, relatives, and staff spoke highly of the new manager and felt they were approachable and improving the service.” from the report
Infection prevention
Inspectors were assured about several infection prevention arrangements, including visitors, personal protective equipment and managing infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines were not always safe
seriousRecords had gaps and were not always accurate. One person did not receive prescribed medicines for five days, and some as-needed medicines lacked suitable instructions.
“We found an instance where someone's prescribed medication had run out of stock and the person had not received their prescribed medicines for 5 days.” from the report
Governance did not drive timely action
seriousAudits found problems such as inaccurate medicine stock records and unsuitable storage, but these issues remained when inspectors visited.
“Audits completed identified areas of improvement, but these were not always actioned in a timely way.” from the report
Care was not always person-centred
needs fixingInspectors observed poor meal-time experiences on two units. People were sometimes given adapted cups even when they preferred ordinary cups and did not need adapted ones.
“People did not always receive person centred care. We observed the dining experience on 2 units and both mealtimes could be improved.” from the report
Cleaning and storage needed improvement
needs fixingThe home was generally visibly clean, but some equipment, storerooms and decommissioned bathrooms needed deep cleaning, sorting and better organisation.
“Storerooms required attention especially the decommissioned bathrooms. These were full of items and not organised, clean or tidy.” from the report
Staffing views were mixed
needs fixingSome people and staff reported delays or times when there were not enough staff. The report says staff later felt this had been resolved.
“One person said, "I just shout for them [staff] and they come. I can be shouting for 30 minutes before they come.” from the report
- 01What changes have been made to ensure every medicine is available, given as prescribed and recorded accurately?
- 02How are as-needed medicines now supported by clear protocols and checked through audits?
- 03Which problems identified in the infection control and medicine audits have been completed, and how do you confirm they stay fixed?
- 04How will meals and drinks be adapted to each person's preferences and needs?
- 05What has changed about staffing levels and response times to call bells since the inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 11 May 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, December 2020
Rated Good overall; inspectors found safe care, but the home needed to improve its management systems and communication with relatives.
This was an unannounced focused inspection. Inspectors visited on 23 November 2020 and reviewed further information up to 27 November 2020. They spoke with people living in the home, relatives, staff and health professionals, and checked care, medicine, recruitment and quality records.
The home was rated Good for Safe. Inspectors found enough staff, safe medicine systems, safeguarding training and suitable action when accidents happened. Some risk assessments missed information, and some parts of the building were difficult to clean, but these issues were dealt with after the visit.
The home was rated Requires Improvement for Well-led. Relatives said communication was not always good and that they did not always feel listened to. Quality checks found problems, but action was not always taken quickly. The overall rating stayed Good because this was a focused inspection and the other areas were carried over from the previous comprehensive inspection.
Safeguarding
Staff understood how to recognise and report abuse. Records of safeguarding concerns were complete and appropriate action had been taken.
“The provider had effective systems in place to safeguard people from the risk of abuse.” from the report
Staffing
Inspectors found enough staff to meet people's needs and spend time with them, including during COVID-19 restrictions.
“We found there were enough staff available to respond to people's needs and to socially engage with them.” from the report
Medicines
People received their medicines as prescribed. Staff had medicine training and regular competency checks.
“Effective systems were in place to ensure people received their prescribed medicines in a safe way.” from the report
Learning from incidents
The management team reviewed accidents and incidents to identify patterns and reduce the chance of similar events happening again.
“Accidents and incidents were analysed, and trends and patterns were identified to ensure future incidents were minimised.” from the report
Communication with relatives
needs fixingRelatives said they did not always feel listened to and sometimes struggled to speak to the right person. The manager had an action plan to improve contact.
“When they say they will ring back they don't, they don't return calls.” from the report
Management structure
needs fixingThe home was struggling to recruit a deputy or clinical lead. Inspectors said this had affected service delivery.
“However, there was no management structure, the service was struggling to recruit a suitable deputy or clinical lead.” from the report
Quality checks and records
needs fixingAudits identified problems, but there were not always clear dates for putting them right. Care plans were not always updated properly and the new systems still needed to become consistent.
“However, we identified care plans had not always been appropriately updated by staff.” from the report
Areas needing maintenance
needs fixingSome store rooms, kitchenettes and sluices were not well maintained, so they could not be cleaned effectively. The provider said these areas had been addressed after the visit.
“Some areas of the home were not well maintained which meant it was not possible to effectively clean these areas.” from the report
- 01How do you now make sure relatives receive promised call-backs and can speak to the right person?
- 02Has the deputy or clinical lead post been filled, and how is the management structure working now?
- 03Have the work to the carpets, store rooms and other areas been completed, and how do you check they remain easy to clean?
- 04How do you check that care plans and risk assessments are updated fully and on time?
- 05What regular updates do relatives now receive about people living in the home?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 25 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 Lodge Care Home
8 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- May 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Goodstayed GoodSafe: GoodWell-led: Requires improvement
- January 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2018Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- May 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2015Inspected but not ratedSafe: InadequateCaring: Requires improvement
- March 2015
Registered with the Care Quality Commission on 30 March 2015.
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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