Byker Lodge

Updated 29 November 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the IPC practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 7 November 2022 and was unannounced.

Updated 29 November 2022

Byker Lodge is a service which provides short stay care for people living with dementia, who require emergency care in crisis situations. The service provides accommodation and personal care and support for a maximum of 25 people. The premises is split over 3 floors, has a communal lounge, two large sunrooms, bathrooms, laundry, garden area, offices and a kitchen/dining area which have all been designed to support and encourage people’s independence. At the time of the inspection there were 18 people using the service.

We carried out an unannounced comprehensive inspection of Byker Lodge on 15 and 16 March 2018. This meant that the provider and staff did not know we were coming.

At the last comprehensive inspection we rated this service overall as good. At this inspection we found the service remained good. We found no breaches of regulations and the service was meeting the legal requirements. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

There was a registered manager in post who had been registered with the Commission since 2011. The registered manager was aware of their responsibilities and had a clear vision for the service in partnership with the provider’s organisational vision. The registered manager had submitted notifications as and when required.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager

The premises were safe. Regular checks of the premises, equipment and utilities were carried out and documented. There were infection control procedures and risk of control of substances hazardous to health (COSHH) in place. The provider had recently reassessed environmental risks and had removed a range of potential risks to people. Medicines were safely managed and there were robust medication policies in place.

People’s care plans reflected their individual needs and risks were assessed and reviewed. We found there were policies and procedures in place to help keep people safe. There was a business continuity plan in place for use in emergency situations. These were also reflected in people’s care plans with personal emergency evacuation plans (PEEPs) to support the safe evacuation of people in an emergency.

We reviewed staffing levels within the service and found these matched the assessed support requirements for people. We reviewed accidents and incidents at the service and found these to be all appropriately recorded, investigated, lessons learned shared with staff and were regularly analysed by the registered manager for themes, trends and further learning. Were applicable referrals had been made to the local safeguarding team and these were also fully investigated with outcomes and actions.

Staff were safely recruited, completed a thorough induction and they were provided with all the necessary training required for their role. There was training provided for staff in delivering end of life care and challenging behaviours in addition to key areas such as safeguarding and moving and repositioning safely. We saw evidence of regular staff supervisions, yearly appraisals and team meetings.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves, for example because of permanent or temporary problems such as mental illness, brain impairment or a learning disability. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When people lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and be as least restrictive as possible.

Staff treated people with dignity and respect. We observed people enjoyed positive relationships with staff and it was apparent they knew each other well. People and their relatives told us that staff knew what they liked and disliked. People received good person centred care which was clearly documented in their care plans. There were records showing assessments of people’s needs prior to entering the service and evidence of regular reviews and further assessments as people’s needs changed. There were regular reviews of people’s care plans with involvement from relatives, other professionals and partnership agencies.

We saw referrals to other agencies, for example the dietician and GP, in people’s care files. People were supported to eat and drink a healthy balanced diet.

People’s privacy and dignity was respected by staff. During the inspection we observed staff asking people discretely if they could carry out personal care and if they required support. The service promoted advocacy and there was accessible information available detailing what support people could access to help make choices about their individual lives.

There was a complaints procedure in place at the service. Any complaints received were logged electronically on the provider’s system, action plans were created and lessons learned from events and incidents were documented. We saw records of activities undertaken by people and relatives told us that people were supported to carry out their own choices for activities.

There was a robust governance framework in place to continually monitor and improve the service. We saw evidence of involvement from the provider’s senior management team and documented audits carried out during their visits to the service. All of the documents we reviewed were accurate, regularly reviewed and very organised with a clear structure.

Further information is in the detailed findings below.