Mount Tryon

Updated 4 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by one Inspector, a pharmacist from our medicines optimisation team, a specialist nurse adviser and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Mount Tryon is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mount Tryon is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider did not complete the required Provider Information Return (PIR). They were in the process of completing the most recent PIR request at the time of our inspection. This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. We received a PIR from the provider shortly after the inspection which was returned inside the requested timescales.

We reviewed additional information we held about the service, this included previous inspection reports and statutory notifications. A statutory notification contains information about certain incidents and events the provider is required to notify us about by law.

During the inspection

We spoke with 8 members of staff which included the registered manager, the deputy manager, members of care staff, catering staff and administrative staff. We spoke with 8 people who lived at the service and 3 people’s relatives.

We reviewed a range of records, including 15 peoples care records, staff recruitment files, records relating to safety checks including fire safety and accident and incident records. We also reviewed medicines records and records relating to monitoring and quality assurance.

Following our site visit we contacted 3 healthcare professionals and received feedback from 2 of them. We also spoke with a further 5 staff members. We continued to seek clarification from the provider to validate evidence found.

Updated 4 July 2023

About the service

Mount Tryon is a residential care home providing the regulated activities of personal and nursing care and treatment of disease, disorder and injury to up to 59 older people, some of which are living with dementia. At the time of our inspection there were 34 people using the service.

People’s experience of using this service and what we found

The provider had failed to ensure governance systems and processes were effectively operated to assess, monitor and mitigate the risks relating to the health, safety and welfare of people at the service. These failings were similar to those identified at our last inspection. Governance processes to assess, monitor and improve the quality and safety of the service were not operating effectively and had failed to identify the issues we found during this inspection.

People were placed at risk of unsafe care as their care was not always planned to reduce risk and records were not accurately maintained. Care records we reviewed were not always accurate in reflecting people’s needs.

Risks around nutrition and hydration were not always managed and care planning around people’s specific care and treatment had not been completed.

Medication management had improved. We identified there were still further areas for improvement but did not identify that this had resulted in any impact on people.

Staffing levels in the service had improved. People and their relatives were positive about the staff team now being stable with no agency staff being used. We received some mixed feedback from staff about staffing levels who felt they were not always supported by the provider to deliver fully person centred care.

Staff received training in safeguarding and knew about the different types of abuse. Staff were able to explain reporting processes. We were assured the service was preventing and controlling the spread of infections.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were processes in place to ensure that accidents and incidents were recorded and analysed to identify trends or patterns. Regular health and safety checks of the environment and equipment used within it were completed.

The provider and registered manager encouraged feedback from people, relatives and staff through questionnaires to improve the service people received. Staff we spoke with were positive about the registered manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 3 February 2023). The service remains rated Requires Improvement. This service has now been rated Requires Improvement for the last 4 consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified continued breaches in relation to safe care and treatment and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow Up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.