This inspection took place on 18 December 2018 and was unannounced.

Byron Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Byron Court accommodates up to 54 people across three separate units, each of which had separate adapted facilities. One of the units specialises in providing care to people living with dementia.

At the time of our inspection there were 39 people living in the home.

A manager was in post, however they had not yet registered with the Care Quality Commission. 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 manager had been in post for the past three months.

We last inspected the home in December 2017 and we rated the service requires improvement overall.

This is the fourth consecutive time the home has been rated ‘requires improvement’. We plan to meet with the provider to discuss this, and any changes they plan to make to ensure this rating improves to at least ‘good.’

During our last inspection in December 2017, we found breaches of regulation in relation to governance. This was because auditing systems were not always robust in identifying missing information in people’s records. We saw during this inspection, that the registered providers approach to quality assurance had improved. However, there were still some discrepancies in records which showed that governance systems, despite being improved, were still not as robust as they should be. We have made a recommendation concerning this.

Our observations and conversations with staff evidenced that there were not always enough staff, particularly on the top floor of the home. We have made a recommendation concerning this.

People told us they felt safe living at Byron Court.

Staff were able to explain the course of action that they would take if they felt someone was being harmed or abused, this was reflected in the organisation’s safeguarding policy.

We saw that risk assessments were clearly accessible for staff and appropriate plans were in place to manage those risks. We saw that risk assessments differed from person to person depending on their level of need.

The manager retained comprehensive records relating to each staff member. Full pre-employment checks were carried out prior to a member of staff commencing work.

We saw that all firefighting equipment had been checked, and new equipment was in place in various parts of the home to help people evacuate safely. There were other environmental checks in place such as the gas and electricity, we spot checked some of these certificates and they were in date.

Medicines were safely stored in medicine trolleys in a locked clinic room. Arrangements were in place for the safe storage and management of controlled drugs. Some people were prescribed topical medicines (creams). These were stored safely and body maps were routinely used to show where topical creams should be applied.

Staff had the correct skills to support people effectively. We viewed the training matrix which evidenced that staff had all been booked to attend courses, and some courses had recently taken place.

Staff received a one to one supervision every eight weeks, and all staff told us that the manager had an open door policy where they were able to request a supervision if they needed one. Appraisals took place annually.

New staff were required to undertake a twelve week programme of induction training which was aligned to the principles of the Care Certificate.

We saw that various improvements had been made to the home since our last inspection. The manager discussed with us that the registered provider was accommodating when it

This inspection took place on 6 & 12 December 2017.

Byron Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Byron Court accommodates 54 people across three separate units, each of which had separate adapted facilities. One of the units specialises in providing care to people living with dementia.

At the time of our inspection there were 36 people living in the home.

A manager was in post and they were in the process of becoming registered with the Care Quality Commission. 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.

We last inspected the home in November 2016 and we rated the service requires improvement overall.

Some paperwork and audits were not organised in a way which reflected good practice. Medicine audits could not be located by the provider and manager despite the provider providing assurance these audits had recently taken place. We did see some evidence of other regular audits and director oversight even though this was not always documented. Therefore it was not always possible for us to see what actions had been taken and how the service was improving. Manager feedback and action points on incident and accident forms was not always completed. External auditors had visited the home and given action points to the service to help them improve. It was not always clear when actions had been implemented as these were not documented anywhere.

We spoke at length with the manager who was new in post about this. They assured us they were putting documentation in place which would help support them adhere to the provider’s own governance requirements.

Medications were managed well. People were getting their medications correctly and on time, and procedures in relation to covert medication were documented. Covert medication is medication which is disguised in food or drink so the person does not realise they are taking the medication. This can only be agreed following’ best interests’ discussions with interested parties including GP involvement. We did not see a record of who was in receipt of covert medication, but the nurse we spoke with knew this information. We raised this with the manager at the time of our inspection who rectified this.

Risk assessments in relation to falls, nutrition and hydration, pressure area care, and moving and handling were regularly reviewed and completed accurately. We saw that when there had been a change to a person’s care needs the corresponding risk assessment had been changed to reflect this.

There were sufficient number of staff on duty to support people appropriately. At the time of our inspection there was a high usage of agency nurses, however our conversations with them indicated they worked at the home often enough to get to know people well.

Staff were able to describe the course of action they would take if they felt someone was at risk of abuse or abuse had occurred. This included reporting the concern to their line manager or speaking to external professionals. We discussed some safeguarding concerns, and where concerns had been substantiated. We looked at what additional actions and learning opportunities had been taken by the service from this.

Staff were recruited safely and all checks were carried out in accordance with the provider’s own recruitment policy. This included satisfactory references and a criminal background check.

Systems and processes were in place to prevent the spread of infection at the home. Hand sanitiser was available on all floors.

Staff had the correct skills and knowledge to enable them to care for people safely and effectively. The training matrix we

This inspection took place on 28 November 2016 and was unannounced.

This inspection was to follow up on concerns that were identified at our last inspection in April 2016 and to check if the provider had made improvements. During our last inspection we found nine breaches of the Health and Social Care Act 2008. The home was judged as ‘inadequate’ overall and placed into ‘Special Measures.’

During our last inspection in April 2016 we found the provider was in breach of regulations relating to risk assessments, staffing, person centred care, consent, complaints, nutrition and hydration, premises and equipment, safeguarding and governance. During this inspection we found that improvement had been made in all areas and the provider was no longer in breach of these regulations.

Byron Court is a care home proving personal care and nursing care. It is registered to provide accommodation for up to 53 adults who require nursing or personal care. There is a separate unit for people who have dementia. The building is large three storey property. A passenger lift provides access to all areas of the home.

There were 44 people living at the home during the time of our inspection.

A manager was in post and they were in the process of becoming registered with the Care Quality Commission. 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.

We found that even though some improvements had been made regarding the application of the Mental Capacity Act and Deprivation of Liberty Safeguards, the provider was not always following a best interest process or clearly documenting this. We saw examples of this in the records we viewed. The provider had improved enough to not be in breach of this regulation, however we have made an recommendation about this.

Staff were able to describe the course of action they would take if they felt someone was being abused or harmed in anyway. Staff had recently undergone training in this subject. During our last inspection we found safeguarding concerns were not always handled correctly and the provider was in breach of these regulations. During this inspection, we found that all concerns had been reported appropriately, and the provider was no longer in breach of this regulation.

We identified during our last inspection that the services approach to risk assessment was not always robust and risks which affected people were not always documented appropriately. We found the provider in breach of these regulations. We found during this inspection, this had improved, and risks to people’s safety and welfare had been adequately assessed and documented. The provider was no longer in breach of this regulation.

There were regular checks in place on the environment and we observed the environment was clean and tidy. During our last inspection we observed that fire doors were wedged open which would compromise the health and safety of people living at the home if there was a fire. We observed during this inspection that the fire doors were being used correctly and were not wedged open. The provider was no longer in breach of regulations relating to this.

Staffing levels were consistent, and there was enough staff on duty to be able to support people in a timely manner. We found during our last inspection that there was a lack of staff presence in most areas of the home, and the provider was in breach of regulations associated to this. We found during this inspection this had improved, and the provider was no longer in breach of these regulations.

Staff were recruited safely and the provider ensured relevant checks were completed on staff before they worked at Byron Court.

Medications were well managed, and the manager had a process in place for the regular checking of medication. People received their medication on time.

Everyone

A responsive inspection took place on 21 and 25 April 2016 and was unannounced. This inspection was to follow up on concerns raised by the Local Authority following recent events at the home. This inspection was also to follow up on concerns that were identified at our last inspection in December 2015.

During this inspection we found that little improvement had been made, and there were still concerns which compromised the health, safety and welfare of people living at Byron Court.

Byron Court is a care home proving personal care and nursing care. It is registered to provide accommodation for up to 53 adults who require nursing or personal care. There is a separate unit for people who have dementia. The building is large three storey property. A passenger lift provides access to all areas of the home.

There were 48 people living at the home during the time of our inspection.

A registered manager was in post and was available for us to speak to for the first day of our inspection. 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.

During our last inspection in December 2015 we found the provider was in breach of regulations relating to medication, risk assessments, staffing, person centred care, failure to display ratings, and governance. The home was rated as ‘inadequate’ overall and placed in special measures.

During this inspection we found there were some audits in place around the cleanliness of the building and medication; however we found a lack of auditing systems around service provision. The current auditing system had failed to highlight the concerns we picked up on during our inspection.

We were told by staff that the staffing provision was not sufficient, and staff felt they could not spend time with people. There was no formal mechanism for determining what the staffing numbers should be based around people’s needs We observed one person was shouting for help and the staff did not come in a timely manner. . There was no staff presence in the lounge on occasions to ensure people’s safety and comfort.

During our last inspection in December 2015, we found the provider was in breach of the regulation associated with the management of risk for people who lived at the home. During this inspection we saw that some risk assessments were in place to help keep people safe from harm.

People were not always receiving care in accordance with their plan of care. Some people were not being weighed regularly, and other clinical tasks that people needed were not always being completed. Some people’s care plans did not contain information such as MUST scores and some information was difficult to find.

There was a process in place for gathering feedback from stakeholders and family members.

Equipment was in place to help support people with their personal care, and this was being regularly checked in accordance with national guidelines, however we saw the weighing scales were not always fit for purpose. One person’s weight was not documented accurately, and another person could not be weighed because the type of scales the home used were inappropriate.

We observed on more than one occasion, that a fire door was wedged open, which presented a risk to people living at the home and others in the event of a fire.

We found the laundry room, a store room and a cupboard were left unlocked and unattended. One contained substances which could be ingested or swallowed by people with dementia by mistake. An area of the home was being used to store wheelchairs which could pose a risk if people had to be evacuated quickly from the building.

Most of the staff we spoke with were aware of abuse. They knew what constituted as a safeguardin

Situated in Bootle, located close to public transport links, leisure and shopping facilities, Byron Court is registered to provide accommodation for up to 52 adults, who require nursing or personal care. There is a separate unit for seven people with dementia. The building is a large three storey property, which is fitted with a passenger lift. There were 47 people living in the home on the day of the inspection.

The manager for the home was registered with the Care Quality Commission (CQC). 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 inspection took place on 2 September 2015 and was unannounced.

We received information of concern prior to this inspection regarding poor standards of care in the home. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to this. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Byron Court Care Home on our website at www.cqc.org.uk .

The home training programme showed that 75% of the nursing staff had not received training or updates relating to catheter care whilst working at Byron Court. The training matrix showed a number of gaps in mandatory training for care staff.

We found people’s nursing care needs were not being effectively monitored. Nursing staff over relied on information supplied by care staff to inform their decision making and review of people’s care. This information was not always effectively communicated or recorded.

People received food and drinks which met their dietary requirements. Some people needed their food and fluid intake recorded when concerns had been raised. We found this was not always done consistently.

People’s physical and mental health needs were monitored and recorded. However we found this was not consistently carried out. Most of the time staff recognised when additional support was required and people were supported to access a range of health care services. We found one person’s weight loss had not been noted and acted upon by staff.

Some people were not weighted regularly in accordance with their plan of care. Weights were not always recorded.

Plans of care did not always record an accurate picture of peoples health needs. Some plans of care and risk assessments in relation to pressure area care and nutrition had not been reviewed recently or on a regular basis. Therefore people’s health was put at risk of being compromised.

You can see what action we told the provider to take at the back of the full version of this report.

We visited Byron Court Care Home to review our findings of non-compliance in three outcomes at our inspection in April 2014.

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found:

Is the service safe?

We last inspected Byron Court Care Home in April 2014. At that time we found there were not enough staff to meet people’s needs, to ensure their care was delivered in a timely manner. Following the inspection the provider sent us an action plan which detailed how the service was to meet the requirements. On this inspection we checked to see whether improvements had been made.

We found the number of staff working throughout the home had increased since our last inspection. The manager advised us that they reviewed staffing levels regularly to ensure there were sufficient numbers of staff on duty to meet people’s needs.

Is the service effective?

Care was planned and delivered in line with people’s assessed needs and people’s needs were regularly reviewed to make sure they received the care and support they required.

People who lived at the home and staff told us that staffing levels were sufficient to ensure people received the care and support they needed. We observed people had staff support with eating and drinking.

Is the service caring?

People who lived at the home described staff as ‘caring’ and ‘kind’. People’s comments included, “Its very nice here” and “I feel quite settled here.” Relatives we spoke with told us, “This home is like a family. The staff are very good.”

We saw that staff were respectful and warm in their interactions with people who lived at the home.

Is the service responsive?

The service worked with other agencies to make sure people received the care and treatment they needed. GPs and other health professionals were referred to promptly when people required support with their health care needs.

Is the service well led?

The service was managed in a way that aimed to protect people’s health, safety and welfare. The manager had taken action to improve the service through providing greater staffing levels. Staff we spoke with felt supported by the manager. Their comments included, “Enjoy working here”, “The manager is making lots of improvements”, “Good training programme”, “Feel supported” and “No complaints”.

At the time of our inspection the manager was not registered with CQC. The manager advised that they intended to submit their application for registration as a matter of priority.

We spoke with five people who lived in the service to gather their views. They spoke positively about the staff saying that they were all "very nice". People who lived in the service also told us that they made day to day choices about their lives.

During our observations we saw that people were offered a choice of food at lunchtime. One person we spoke with told us that there was always something they liked offered from the choices of main meals and snacks. They said that they could have breakfast between certain times, to be able to have a lie in and could have a light or cooked breakfast if they wished. This showed people made their own choices.

On checking medication management we found that people received their medicines as prescribed. We found records regarding medication were accurate.

We observed staff interacting with people who lived in the service during our visit. We observed some examples of where staff supported people well, such as acknowledging anxieties and attempting to reassure them and assisting them with around the building.

People expressed their views and were involved in making decisions about their care and treatment. For example we spoke with one man whose wife has dementia and is unable to make decisions for herself. “I am consulted about everything relating to my wife’s care.”

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We spoke with one person who told us how staff had supported them with what she needed.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We saw that people who lived at the house were very relaxed and confident around staff. This shows that people feel safe in the home. Those spoken with were very relaxed around staff and said that generally they were listened to so that any concerns could be addressed.

There were effective recruitment and selection processes in place to ensure staff could work with vulnerable people. We received positive comments about staff and their approach. One said, “It’s a great place here, the staff are brilliant.” A relative we spoke with told us, “Anything my dad needs the staff get for him. “

Staff received appropriate professional development. People we spoke with told us that they were supported well by Byron Court and staff were always available to assist and help as needed.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. All of the people we met with were living in accommodation that suited their needs. They told us they enjoyed living in their home and were able to talk about any changes they wanted at the residents’ meetings.

A Comprehensive inspection took place on 8 and 21 December 2015 and was unannounced. This inspection was also to follow up on the concerns that were identified at the previous inspections in June and September 2015. Although some improvements had been made, several concerns still remained and this compromised the health, safety and welfare of people that lived at Byron Court.

Byron Court is a care home providing personal and nursing care. It is registered to provide accommodation for up to 52 adults, who require nursing or personal care. There is a separate unit for seven people with dementia. The building is a large three storey property. A passenger lift provides access all areas of the home.

There were 49 people living in the home at the time of our inspection.

A registered manager was in post. 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.

Improvements to the safe management of medicines had been made however some concerns were apparent in relation to the recorded keeping and safe storage of medicines.

There were not enough staff on duty at all times to ensure people were supported safely. Staff told us they needed more staff to support people with their care needs in a timely manner.

People had their needs assessed and staff understood what people’s care needs were. However, some people’s care plans, health needs and risk assessments were not regularly reviewed. People had still not been weighed regularly as they should have been following specialist input. Food and fluid charts had still not been completed therefore it was impossible to tell what people had had actually eaten or drank. All of this put people at unnecessary risk of harm.

People’s physical and mental health needs were monitored but not always recorded. Staff recognised when additional support was required and people were supported to access a range of health care services.

There was a lack of good governance and leadership at the home. Although the service had a quality assurance system in place it was not robust enough in order to ensure the health, safety and welfare of people was effectively assessed and monitored.

The service had not displayed the ratings to the public from either the June 2015 or the September 2015 inspections as they are legally required to do so.

There were systems in place to get feedback from people so that the service could be developed with respect to their needs.

We saw the necessary recruitment checks had been undertaken so that staff employed were suitable to work with vulnerable people. Staff said they were well supported through induction, supervision, appraisal and the home’s training programme.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment and equipment. Some changes had been made to the environment of the dementia unit to help promote a positive dementia- friendly environment.

Staff sought people’s consent before providing support or care. The home adhered to the principles of the Mental Capacity Act (2005). Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority. Staff had a good understanding of the Mental Capacity Act (2005) about how the act applied in a care home setting.

People told us they received enough to eat and drink, and they chose their meals each day. They were encouraged to eat foods which met their dietary requirements.

We saw that people were involved in the decisions about their care and support, and in choosing what they wanted to do each day. They told us staff treated them with respect.

Staff we spoke with were knowledgeable and showed they had a very good understanding of the people they were supporting and were able to meet their needs. We saw that they interacted well with people in order to ensure people received the support and care they required. We saw that staff demonstrated kind and compassionate support. They encouraged and supported people to be independent both in the home and the community.

Referrals to other services such as the dietician or tissue viability nurses and GP visits were made in order to ensure people received the most appropriate care.

The home had a complaints policy and processes were in place to record complaints received. This helped ensure issues were addressed within the timescales given in the policy.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.