Byron Court Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff had clearly defined roles and responsibilities. A range of governance systems were place and regular checks were carried out on all areas of care provision. However, they were not always effective at identifying and addressing concerns about risk management and medicines practice in a timely way. We found no evidence people had been harmed. However , systems were not always effective at identifying concerns to improve the quality and safety of the service. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Concerns were investigated in a sensitive and confidential way, and lessons were shared and acted on. There was a range of governance systems in place and regular reviews were scheduled on all areas of care provision. However, these systems were not always effective at identifying and addressing areas that required improvement in a timely way. For example, care plan audits did not identify all shortfalls found with care plans and risk assessments and medicines audits did not identify all shortfalls found with medicine administration records. Policies were in place to ensure the safe storage of people's confidential information. However, these procedures were not always followed as we observed people's confidential information accessible around the building.

Staff understood their role and responsibilities and were motivated. The registered manager understood the importance and responsibility of their role. They had already identified the quality of people's care records and medicines processes needed to improve. They told us they were supported by the provider and extra resources had been provided to increase the auditing of care plans. The registered manager was honest about the recent transition to electronic medicines records and the challenges they had experienced. Prior to the assessment, the they had contacted the local authority medicines management team for support and guidance. We found the registered manager responsive to the feedback we provided during the assessment. They took immediate action to improve some areas and committed to developing an action plan to improve the overall quality and safety of the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.