Mount Tryon

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.

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 44 people using the service.

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

The provider had failed to ensure systems and processes were effective to drive improvement and prevent repeated themes of concern re-occurring in relation to people’s safety, the quality of care at Mount Tryon.

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 needs and associated risks had not been routinely monitored appropriately. People's monitoring charts were not being completed consistently in relation to skin care, nutrition and hydration.

We were not assured there were enough staff to meet people's needs. People, relatives and staff told us they did not feel there were always enough staff on duty to meet their needs. We observed people waiting for personal care late into the morning and people having to wait for staff to assist them to the toilet.

Systems used for the management of medicines were not always safe. The provider could not be assured that people received their medicines or prescribed creams as they should as some records were incomplete. Records did not accurately reflect the medicines stored at the home.

Staff received training in safeguarding and knew about the different types of abuse. However, staff had not ensured a potential allegation of abuse was escalated appropriately. We made a recommendation about this.

We were assured the service was preventing and controlling the spread of infections. Some concerns about the cleanliness of people's rooms and bedding were reported and being addressed by the registered manager.

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, actioned, and analysed.

Risk assessments were person-centred and detailed, and staff understood and were able to describe the care and support people needed. Regular health and safety checks of the environment had been completed.

The provider and registered manager encouraged feedback from people, relatives and staff through questionnaires to improve the service people received.

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

Rating at last inspection

The last rating for this service was requires improvement. (Published 13 January 2022)

At our last inspection we recommended the provider consider current guidance to ensure the safe administration of topical medicines. At this inspection we found that the administration of topical medicines had not improved.

We also found further concerns with the safe administration of medicines, safe care and treatment, staffing and good governance. We made a recommendation in relation with safeguarding people from abuse.

Why we inspected

The inspection was prompted in part due to concerns received about the quality of care provided and staffing levels at the service. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mount Tryon on our website at www.cqc.org.uk.

Enforcement and Recommendations

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

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Mount Tryon is a care home. It is registered to provide personal and nursing care for up to 59 people across two floors, each of which has separate adapted facilities. At the time of our inspection 48 people were living at the service.

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

People were at risk because the providers quality assurance systems were not fully effective. They had not identified issues we found during the inspection relating to gaps in medicines records; the setting for a pressure mattress; emergency evacuation plans and staff wearing PPE correctly. The registered manager responded immediately during and after the inspection to address the concerns raised.

The registered manager had been managing another of the providers locations, in addition to Mount Tryon. The deputy manager, who was also the clinical lead, had additional responsibilities during this period to support the management of the home. The registered manager had now returned to Mount Tryon full time.

There were processes in place to keep people safe from the spread of COVID-19, although improvements were needed to ensure staff were wearing personal protective equipment (PPE) correctly.

There had been difficulties with staffing and recruitment which the provider was working to address. A dependency tool was used to calculate staffing numbers.Staff from all roles worked across both floors to cover any shortfalls. Staff told us they were able to meet people’s basic needs at these times. The provider was clear this had not impacted on the quality and safety of the support provided.

Measures were in place to mitigate the risk of deteriorating mental health due to a lack of stimulation and activities. The providers dementia specialist was reviewing the support for people living with dementia, and two ‘dementia champions’ had been appointed. A new activities co-ordinator was due to start. Environmental improvements were about to begin in the Memory Lane community, the providers specialist resource for people living with dementia. This had been delayed for 18 months by the restrictions of lockdown.

Staff were caring and kind and had developed positive and meaningful relationships with people. People were respected, included in decisions and their privacy and independence promoted. The care provided was sensitive to people's diverse needs.

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.

Risks associated with people's care had been assessed and guidance was in place for staff to follow. Care plans were detailed, person centred and reviewed regularly. There were systems in place to ensure information about any changes in people's needs was shared promptly across the staff team.

People were supported by suitably trained, competent and skilled staff. This meant their healthcare and nutritional needs were met. Overall external professionals were complimentary about how the service worked in partnership with them, although this had been more challenging with the restrictions of lockdown.

There were effective systems in place to protect people from the risk of abuse. Concerns were escalated appropriately to the local authority, and investigations completed as required. Lessons learnt from accidents and incidents were used to prevent reoccurrences. Staff were recruited safely.

The management team led an open, transparent and person-centred service which helped people and staff feel valued and supported. They were committed to continuing to learn and improve, responding immediately to feedback given during the inspection and undertaking to address any concerns raised.

People, staff and relatives spoke positively about the registered manager and the management of the service. Relatives commented; “The manager is the best they have had in ten years “and, "He is really nice and capable. They went through three or four managers; he certainly turned the home through a bad patch."

We have made a recommendation about the safe administration of topical medicines.

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 27 July 2021) and there were breaches of regulation related to dignity and respect; safe care and treatment and good governance. At this inspection improvements had been made and the provider was no longer in breach of the regulations.

Why we inspected

We received concerns in relation to staffing and the management of risk. As a result, we undertook a focused inspection to review the key questions of Safe, Caring and Well-led.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service remains requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mount Tryon on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.

Mount Tryon is a care home. It is registered to provide personal and nursing care for up to 59 people across two floors, each of which has separate adapted facilities. At the time of our inspection 43 people were living at the service.

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

Risks to people were not always managed safely. Medicines management was not always based on current best practice. Peoples personal preferences and lifestyle choices were not always respected.

The systems in place to monitor the quality of service were not always effective. The culture within the service was not always positive and constructive.

The service met the accessible information standards. The Accessible Information Standard (AIS) was introduced by the government in 2016 to make sure that people with a disability or sensory loss are given information in a way they can understand. It is now the law for the NHS and adult social care services to comply with AIS.

The provider, managers and staff were enthusiastic and committed to further improving the service delivered for the benefits of people using it.

People’s independence was promoted, and enough staff were available to meet people's needs and people told us when they needed assistance, staff responded promptly. The premises were clean, and staff followed infection control and prevention procedures. People's needs were assessed, and care was delivered by staff who were knowledgeable about people's care and support needs.

People were encouraged to maintain a good diet and access health services when required. People had access to a wide range of activities and were supported to avoid social isolation.

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.

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

Rating at last inspection

The last rating for this service was Good (published 27 June 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing, medicines and the management and leadership of the service. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Caring and Well-Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safety, lifestyle and choice and governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

Systems were in place to help manage the risks and prevent the spread of COVID-19.

There were clear systems in place for visitors to ensure they followed the current guidance on infection prevention and control. On arrival, visitors had their temperature checked, were screened for COVID-19 symptoms. Where appropriate, visitors were required to take a lateral flow device (rapid) test to confirm that they did not have a COVID-19 infection before they were allowed into the home.

The registered manager was aware of the latest government guidance regarding visiting to care homes and were facilitating visits in line with the guidance. Staff understood how important this was to people living at the home and their families and friends. Additional arrangements, such as, garden visits and visits in an enclosed visiting ‘pod’, were also in place. This helped people receive visitors in addition to their nominated family members who were able to visit them inside of the home.

Staff had received training in infection prevention and control and the use of PPE including masks, gloves, aprons and hand hygiene. There were sufficient stocks of PPE available and staff were seen to be wearing PPE appropriately and in line with government guidance.

People and staff took part in regular COVID-19 'whole home' testing. People and staff who tested positive, followed national guidance and self-isolated for the required amount of time.

Cleaning schedules had been enhanced to include more frequent cleaning of touch points such as handrails and light switches. In addition, the service carried out monthly infection prevention and control audits.

The provider had developed specific COVID-19 policies and procedures which had been reviewed and updated where necessary in line with the latest guidance.

There was a contingency plan and risk assessment in place to manage a potential outbreak of COVID-19 within the service to keep people and staff safe.

Prior to the inspection, the home had undergone extensive refurbishment which included a number of bedrooms being redecorated, fitted with new furniture and the en-suite toilets renewed to a very high standard. At the time of the inspection 37 people were living at the home. However, this number was expected to rise over the coming few weeks as the newly refurbished bedrooms were now available.

The home was inspected on two occasions in 2017. In February and March 2017 a comprehensive inspection resulted in the home receiving an overall rating of ‘requires improvement’. We found improvements were required in how the home shared information about people’s nutritional needs to ensure these were fully understood by all those staff involved in people’s care. The policies and procedures relating to providing safe care had not been consistently followed by the nursing staff.

In October 2017 a focused inspection of the key question, ‘Is the service safe?’ identified improvements had been made and the home’s overall rating improved to ‘good’.

At this inspection, in May 2018, we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. The key question of ‘Is the service well-led?’ has an improved rating from ‘requires improvement’ to ‘good’. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated good.

The home had a registered manager, appointed following the previous inspection in October 2017. People, relatives and staff told us the home was well managed and registered manager was supportive and approachable. Effective quality assurance systems, including care reviews, meetings and audits, ensured people received the care and support they required in a safe environment.

Sufficient numbers of well trained staff were on duty. People and relatives described staff as kind, caring and compassionate. Our observations showed staff were knowledgeable about people’s care needs, attentive to people and it was clear they had developed close relationships with them. Staff told us they were proud to work at the home.

People were protected from the risk of abuse as staff recruitment practices were safe. Staff had received training in the protection of adults. Other risks to people’s health, safety and welfare, such as the risk of falls or not eating or drinking well, were assessed and care plans provided guidance for staff about how to mitigate these risks.

Medicines were managed safety and people’s healthcare needs were monitored and guidance sought from healthcare professionals when necessary.

People were supported to make decisions about their care and to have maximum choice and control of their lives. People rights were respected and protected. Staff supported people in the least restrictive way possible; the policies and systems in the home supported this practice. Care plans provided staff with clear guidance and information about people’s specific care needs, what to be observant for to indicate a person’s health might be declining and what actions to take.

People and relatives told us they were very happy with the care and support they received. One person described this as “excellent” and another as “brilliant”. Two relatives said their relatives’ health and well-being had improved as a result of the care they received. One relative said, “She's come on leaps and bounds since she's been here.” None of the people or relatives we spoke with had any complaints about the home. All said they felt they could discuss any issues of concern with the staff and registered manager.

People spoke extremely highly of the food, describing it as “excellent”. People were offered a choice of meals at the time of serving with some people being shown plates of food to help them decide what they would like to eat. For those people who needed support we saw this was done appropriately with staff sitting with people, encouraging them to eat and engaging them in conversation.

Activity co-ordinators ensured people had the opportunity to become involved in leisure and social activities. People were able to contribute to activity planning and were provided with a timetable of daily events. The home held regular events where people from the local community were invited to visit the home.

Since the previous inspection in October 2017, the redesign and refurbishment of the ground floor had been completed to a very high standard. The home was clean and very well maintained.

Further information is in the detailed findings below.

Through our ongoing monitoring and during our inspection activity, no risks or concerns were identified in the four remaining Key Questions, (Is the home effective, caring, responsive and well-led?), so we did not inspect. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

As a result of this inspection, we found no evidence that the safety and welfare of people was being placed at risk.

Mount Tryon is a care home with nursing. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide care for up to 59 older people, people with a physical disability, people living with dementia and younger adults. Care is provided in two separate areas of the home: a nursing unit on the ground floor and a dementia care unit on the first floor. On the first day of inspection there were 36 people living at the home: 17 people in the nursing unit and 19 people in the dementia care unit. We looked at the care given to people on both units.

The home did not have a registered manager. 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.

An interim manager had been in post since the previous manager left the home in August 2017. Since then a manager had been appointed and they had started to work at the home on 30 October 2017. They were available during and following the inspection and they told us it was their intention to apply to register with the Care Quality Commission.

The home was also supported by a clinical development nurse employed by Barchester Healthcare Homes Ltd. They had the responsibility to support the nursing staff to assess, review and plan for people’s nursing care needs.

Mount Tyron was previously inspected in February and March 2017. As a result of that comprehensive inspection, the home received an overall rating of Requires Improvement as we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found improvements had been made, and there were no breaches of regulations.

People told us they felt safe living at Mount Tryon. One person said, “Yes, everything is fine” and another “It’s very nice.” Relatives described the care their relations received as “outstanding” and “excellent”.

Risk assessments and management plans were well documented. Actions required to keep people safe were communicated effectively throughout the staff team, including all support staff. This included catering and housekeeping staff. Each person’s care file contained assessments to identify risks associated with their care needs, and clear guidance for staff about how to mitigate these risks. We reviewed the daily care records written by staff and these showed people were being supported in line with the recommendations and guidance in the care plans.

Records showed any accidents, such as falls, were documented at the time of the incident and reviewed by the nurse in charge of the care unit as well as the interim manager. The forms were reviewed to identify how the accident came about and whether any further action was required to reduce the risk of a reoccurrence. Records also showed when staff had contacted health care professionals over people’s care needs.

People received their medicines safely and as prescribed. Records relating to the receipt, storage and disposal of medicines were well maintained. One of the rooms used to store medicines was found to be warm: the temperature of the room was close the the maximum recommended by the Royal Pharmaceutical Society. The interim manager immediately made arrangements for the fitting of an air conditioning unit and this was done on 26 October 2017.

There were sufficient staff on duty both during the day and overnight to meet people’s care needs. Duty rotas showed staffing had not been reduced. Concerns had been raised with us about people getting up early, from 5am, as there were insufficient staff on duty during the mornings. We visited the home at 6am on 31 October 2017 and found no evidence to support this. Those people awake and out of bed at this time were happy to be up. We looked at the duty rota over a four-week period and found the staffing levels to sufficient and consistent each day including the weekends, and that staffing levels had not been reduced.

People and relatives had no complaints about the quality of the care and support provided. Their comments included, “I’m very happy with the care I get” and “Can’t find fault”. People told us the staff were kind, caring and friendly. One person described the staff as “exceptional” and another as “wonderful”.

At our previous inspection in February and March 2017 we found staff had been safely recruited to work at the home. At this inspection we found this safe practice continued. The three staff files we looked at all contained the necessary pre-employment checks, including with the Nursing and Midwifery Council for the registered nurse recently recruited.

This inspection started on 1 and 2 February 2017. We revisited the home on the evening of 12 March and during the day on 29 March 2017 after we received concerns about insufficient staff on duty, particularly at weekends, whether people could have something to eat during the night and whether people were receiving safe care and support. The first and third days of the inspection were unannounced.

Mount Tryon has been inspected on five occasions since it was rated as requires improvement in all five key questions at the comprehensive inspection undertaken in January 2015. Since that time, CQC has continued to require improvements and/or made recommendations for improvement. In March 2016 CQC issued a warning notice to the provider as they had failed to ensure the nutritional and hydration needs of service users were met.

In May 2016 the provider had met the requirements of the warning notice but was in breach of a number of other regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Mount Tryon was placed in 'special measures' as it had been rated as 'Inadequate' in a key question over two consecutive inspections.

Following the inspection in May 2016 the provider sent us a detailed action plan telling us how they would resolve the issues identified at the inspection.

In September 2016 an unannounced focused inspection took place in response to concerns raised with us about whether the home was monitoring the food and fluid intake of people who may be at risk of not eating and drinking enough to maintain their health. At that inspection we found concerns relating to the monitoring of one person’s nutrition and hydration needs to be substantiated but other people’s needs in relation to their diet and fluid intake were being reviewed, monitored and met.

You can read the reports from our previous inspections, by selecting the 'all reports' link for Mount Tryon on our website at www.cqc.org.uk.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The home had a registered manager. 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.

At our previous inspections we found improvements were required in how the home was being managed. In May 2016 we identified changes to the management and leadership within the home and at regional level and had led to weak and inconsistent management, leadership and ineffective oversight of the service. At this inspection we found improvements had been made to internal management and oversight systems. However, there had been some failing by the nursing staff to fully implement the home’s policies and procedures to review and manage risks to people’s safety. This had led to one person being left with food that had not been suitably prepared for them to eat safely.

Since coming into post the registered manager had developed an action plan relating to the improvements needed. They had involved staff and relatives in this plan and had ensured each member of staff understood their role in bringing about improvements. By being transparent and honest, the registered manager had been able to involve the whole home in bringing about improvements. In doing so, a culture of kindness, which we saw evidence of throughout our inspection, had been created. The registered manager had further developed the leadership and nursing teams to support them, through training, supervision and oversight to bring about the changes needed. People and their relatives told us of the positive impact this had had on people’s experience.

At the previous inspection in May 2016, we found the care plans were bulky documents and it was difficult to find the most up to date information. At this inspection we found improvements had been made to the ease of reference within the care files. Also there were improvements in relation to reducing people’s risks of developing pressure ulcers and for those at risk of not eating and drinking enough to maintain their health.

People and their relatives told us there had improvements to the management of the home, including less use of agency staff, as well as improvements to the care and support their relatives received. One person described the registered manager as “excellent” and a relative said the improvements in the home were due to the registered manager’s influence. Relatives also told us they “couldn’t speak more highly” of the deputy manager and one of the nurses who had worked at the home for some time. People told us they felt listened to and were able to raise any concerns. They said they would recommend the home to others.

Systems to monitor people’s well-being and the quality of the service were in place and had contributed to the improvements being made in the home. Robust systems had been introduced to monitor people’s clinical care needs. Nursing staff had greater oversight than at previous inspections in monitoring people’s well-being and taking action to ensure people’s needs were being met. Regular audits and monthly reports about a number of issues relating to people’s care and the safety of the environment were being undertaken: these included audits of whether anyone had developed a pressure ulcer, become unwell with an infection or had an accident. The outcome of these audits was reported to the provider’s clinical development team who reviewed the results to monitor for any trends, such as people falling more frequently. They also provided guidance and support if necessary in managing people’s clinical care needs. People’s risks in relation to their nutritional needs were being well managed. Records for three people identified as being at risk of not eating enough showed they had either maintained they weight or had gained weight.

Many of people living at Mount Tryon were unable to share their experiences of living at the home with us. Those people who were able told us they felt safe and well cared for. Relatives also told us they felt their relatives received safe care and staff were knowledgeable about their care needs. People were referred to a variety of healthcare professionals and a relative told us the care staff were observant for changes in people’s health and well-being. They gave us an example of when staff had acted promptly to ensure their relative received appropriate care from a specialist.

People were protected from the risk of abuse and poor practice. Staff had received training in safeguarding adults during 2016. They knew who to report concerns to, both in and outside of the home, and said poor practice or neglect of people’s care would not be tolerated by the registered manager. Relatives and staff told us staffing levels had improved since our inspection in May 2016 and the home was less reliant upon agency staff. Staff said there were enough staff on duty and they didn’t feel rushed when supporting people. During our inspection we saw staff attending to people’s call bells promptly and people told us they do not have to wait long for staff to assist them.

Staff received training in a variety of care and health and safety topics including caring for people living with dementia, meeting people’s nutritional needs and safe moving and transferring. At the previous inspection in May 2016 we identified staff new to the home had not had been provided with training to introduce them to the home and to people’s care needs. Since then the registered manager had ensured all newly employed staff were provided with induction training. This included a number of classroom days for essential health and safety training, shadowing experienced staff and for those new to care, completing the Care Certificate. The registered manager had recently introduced an initiative to provide staff with more insight into the needs of the people living the home and how it felt to be reliant upon staff to meet their care needs. Staff volunteered to be a “resident for the day”. They were given a scenario to follow which identified their needs and how they were able to communicate with staff. Staff told us they felt this would provide them with valuable insight in to people’s experiences.

The registered manager was aware that as some of the staff were new to their role they lacked confidence in supporting people with complex needs and those who had limited communication abilities. It was an issue they and the nursing staff were addressing through supervision, role modelling and with the ‘resident of the day’ initiative. During our observations we saw times when staff were not attentive to people. At other times staff showed great interest in, and kindness to, people: this included not just care staff, but the administrative, kitchen and laundry staff. People told us the staff were kind and polite to them. Their comments included, “I’m being taken care of very well” and “the staff were lovely”. Relatives were also complimentary about the staff and the way in which they met people's needs. One said, “I don’t have any con

This unannounced focused inspection took place on 21 September 2016 in response to concerns raised with us. These concerns related to whether the home was monitoring the food and fluid intakes of people who may be at risk of not eating and drinking enough to maintain their health. During this inspection we looked at whether people who were at risk of dehydration and malnutrition, were receiving safe care and treatment and whether the service was monitoring the support people received in relation to their nutritional and hydration needs.

Mount Tryon has been inspection on four previous occasions since it was rated as ‘requires improvement’ at the comprehensive inspection undertaken in January 2015. In October 2015 a comprehensive inspection continued to rate the service as ‘requires improvement’. At both these inspections the service was required to improve how it ensured people received safe care and treatment and how it monitored the quality of care and support provided. In January 2016 an unannounced focused inspection was undertaken in response to concerns regarding the number of staff on duty. As a result of that inspection we made a recommendation that the home review its staffing arrangements at mealtimes in order for people to receive their meals promptly.

In March 2016 an unannounced focused inspection was undertaken in response to concerns that people were not being supported to eat or drink enough to maintain their health. At that inspection we found records were either not maintained or were incomplete and the arrangements to ensure people were supported to have a meal in a timely way still required improvement. We found there was insufficient oversight by nursing staff and management to ensure people received safe care and treatment. As a result we issued a warning notice to the provider as they had failed to ensure the nutritional and hydration needs of service users were met.

In May 2016 we undertook an unannounced comprehensive inspection as we had received concerns regarding staffing levels and whether staff were receiving the training they needed to carry put their roles; poor record keeping, particularly in relation to people’s food and fluid intake, and the manner in which the service responded to complaints. At that inspection we found the provider had met the requirements of the warning notice issued in March 2016 but was in breach of a number of other regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people not receiving care that met their needs and reflected their preferences; the unsafe management of medicines; poor management of complaints; ineffective systems to monitor the quality of care provided by the service and staff not receiving an induction that prepared them for their role.

As a result of the inspection in May 2016, the service received an overall rating of 'Requires Improvement'. Mount Tryon was placed in 'special measures' as it had been rated as 'Inadequate' in a key question over two consecutive inspections.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame. If not enough improvement is made within this timeframe so that there is still 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 this service.

Following the inspection in May 2016 the provider sent us a detailed action plan telling us how they would resolve the issues identified at the inspection.

This report only covers our findings in relation to the inspection in September 2016. You can read the report from our previous inspections, by selecting the 'all reports' link for Mount Tryon on our website at www.cqc.org.uk.

The home had a registered manager who had been appointed in May 2016. 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 this inspection we found the concerns relating to the monitoring of one person’s nutrition and hydration needs to be substantiated. Records showed this person’s food and fluid intake to be better on some days than others and although they were maintaining a stable weight, they remained at risk of always not eating and drinking enough to maintain their health. The registered manager confirmed the decision to stop the monitoring records had been undertaken by a nurse without consultation with them, and it was not a decision they supported. While the initial response from the registered manager prior to this inspection did not provide us with assurances that this person’s needs were being monitored closely, the inspection found that action had been taken to reinstate this person’s records and to review why the decision had been made. We found other people’s needs in relation to their diet and fluid intake were being reviewed, monitored and met.

The risks associated with eating and drinking, such as choking due to swallowing difficulties, or poor intake due to a loss of interest in food and drinks, had been assessed for all those living at the home. For those people who had been identified as at risk professional advice had been sought from the GP, dietician and the community speech and language team. Management plans were in place to reduce these risks and careful monitoring ensured issues were identified early to allow for further intervention. Food and fluid intake records were carefully monitored and staff shared the responsibility for this and for taking action should there be a concern. These records showed people were receiving enough to eat and drink to maintain their health.

Staff were guided about how to prepare people’s food and drinks and care plans provided information to staff about how to support people safely. For those people who may have lost interest in food or who declined their meals, alternatives were suggested and people’s more favoured foods were identified and encouraged.

Many of the people living at the home needed staff support to eat and drank, and were eating and drinking well. The staff told us that if this changed, they would report to the nurse on duty and they would commence monitoring of their intake.

This inspection in May 2016 took place over three days. The first visit started at 9pm on a Saturday evening.

There had been a number of management changes at Mount Tryon which had negatively impacted on the care and support people had received. These changes had occurred both at service level and at regional level. Actions to address risk had either not been taken or taken and not sustained through those changes.

Mount Tryon did not have a registered manager. 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. A new manager had been appointed and had applied to CQC to register as manager.

Since January 2015 Mount Tryon had been inspected on five occasions. Each of those inspections had resulted in CQC telling Mount Tryon that improvements were needed to ensure people received a safe, responsive, effective, caring and well led service.

The service was last inspected in March 2016 in response to concerns we had received about whether people had enough to eat and drink in order to maintain their health. That focussed inspection found the service could not demonstrate people were being supported to eat and drink enough. We issued a warning notice telling the provider they must take action by 18 April 2016. During that inspection we also found people were not receiving safe care and quality assurance systems failed to identify and address risk.

During this inspection in May 2016 we found the warning notice had been complied with. However, whilst people were receiving enough to eat and drink, records were not always up to date or accurate. Records kept in relation to what people eat and drink are an essential part of any risk management strategy and must be up to date and accurate.

In January 2016 we carried out a focused inspection in response to concerns about staffing levels, the high use of agency staff and staff lacking the knowledge to meet people’s needs safely. We found no evidence to support those concerns. However, we made a recommendation that the level of staffing at mealtimes be looked at in order for people’s nutritional needs to be met promptly. In response to this, we were told Mount Tryon had set up two meal time sittings to ensure there were always enough staff on duty. We found at this inspection in May 2016 that this had not continued, and there were not enough staff to support people with eating at all times in a person centred way.

We carried out comprehensive inspections in January 2015 and October 2015. These resulted in an overall rating of ‘requires improvement’ on both occasions. Our main concerns were that people were not receiving safe care and treatment and the service was not well led.

Prior to carrying out this comprehensive inspection in May 2016 we had received concerns relating to: insufficient staff, particularly at night, to meet people’s needs; staff not having the skills or knowledge to meet people’s needs, especially in relation to people living with dementia; Induction for new staff was insufficient; people were still up at 1am or 2am due to lack of staff to help them to bed; people being funded for individual staffing were not receiving this; there were no snacks on the drinks trolleys for people on soft diets; no beakers were left in people’s rooms when jugs of drink were left; the management of the service did not take note of relative’s concerns and did not inform them of changes in people’s health; there was poor recording on people’s food and fluid charts; there was poor communication between staff. This and the poor recordings meant staff did not have up to date information about people.

We found that some of the concerns raised with us were founded. There were sufficient staff at night, and there was no evidence people waiting until 1 or 2am to go to bed. However, on the night we inspected all the staff on night duty were agency staff who would not be as familiar with the home or people as permanent staff. Important information about people was not always communicated to staff.

Induction for staff was not robust. Although staff training had not been sufficient for all staff, it was being enhanced. We did not find evidence that staff did not have the skills to care for people with dementia. Snacks were available for people but the management team, nurses and carers could not assure themselves that people were getting enough to eat and drink because records were incomplete. We saw one person did not have a beaker from which to drink. We found relatives were updated about people and complaints were investigated. However, one person was restricted to raising further concerns by email to a named person only. This meant the complaint system was not fully accessible to them and could lead to a delay in any necessary action being taken.

During the inspection the new management team shared with us their drive to improve the communication, leadership and culture within the home. However, the provider did not always enable and encourage open communication with people who use the service and those that matter to them.

There were few effective quality assurance systems in place to monitor care and plan on-going improvements. Records were not well maintained. Re-positioning charts were not always completed and care planning documents contained conflicting information. Care plan documents were lengthy and it was difficult for staff to find the most up to date information about people. Reviews did not always reflect the current needs of people. People’s risk assessments were not always up to date. This meant people were at risk of not having their identified needs met appropriately.

Staff understood the principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards (DoLS). We heard that relatives had been involved in making best interest decisions about their relation’s care. However, records did not always support this.

Some aspects of medicine management were not safe. There were gaps on Medicine Administration Records (MAR) and topical cream application records. This meant it was not possible to confirm people had received medicines as they had been prescribed. We also found cupboards containing medicines open and accessible to people living at the home and to visitors.

We saw one person’s pressure ulcer had improved significantly and that another person’s weight had increased. Staff ensured people received personal care and support that was responsive to their needs. People’s needs were met by kind and caring staff. Staff ensured people’s privacy and dignity was respected and all personal care was provided in private.

People’s needs were met in a safe and timely way as there were enough staff available, except at meal times when one member of staff was supporting three people to eat. The high reliance on agency staff at times meant people were not always cared for by staff who knew them well. One person said the staff were very good and they could “find no fault” with the home. One relative told us if they ever had to move into a care home they “would be happy to live in this home”.

People told us they enjoyed the meals. One person said the food was “excellent”, and another told us the food was “very good” with “plenty of choice”. There was a good selection of meals prepared each day as well as a menu of other meals that could be prepared upon request.

People were protected from the risks of abuse as staff knew how to recognise and report abuse. Thorough recruitment procedures ensured the risks of employing unsuitable staff were minimised.

An activity organiser was employed for 40 hours per week and we saw some activities taking place. We saw people taking comfort from cuddly toys and dolls. One person enjoyed pushing a pram in and out of the lounge. However, there were limited opportunities for people to engage in meaningful interaction and activities.

People, staff and visitors felt the service was improving. Although it had not always been the case, people were confident that if they raised concerns they would be dealt with efficiently. People had confidence in the new manager and felt things had already started to improve. All the issues we identified during our inspection had already been identified by the management team. Everyone’s care plans were to be reviewed and the management team would be working alongside staff to ensure they were provided with support and mentoring. How well staff performed their duties and their contracts were also to be reviewed. We were told this was important as previously there had been ‘no consequences’ for staff who had failed to meet expectations.

We have made recommendations in relation to documentation relating to mental capacity assessments, the provider’s policy on restricting visiting and the provider’s communication systems.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over

There was a registered manager in post however they were not available at the time of this 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.

This unannounced inspection took place on 2 March 2016. The inspection was a focused inspection in response to concerns we had received about whether people were receiving enough to eat and drink to maintain their health. We therefore only looked at how well people were supported with their nutritional and hydration needs.

At our last comprehensive inspection of Mount Tryon in October 2015, the home was rated as ‘requires improvement’ with breaches of the Health and Social Care Act 2008 Regulations 2014 identified in Regulation 12, safe care and treatment and Regulation 17, good governance. The provider sent us an action plan which said the actions to address the issues would be completed by 1 March 2016.

The home was also inspected on 20 and 22 January 2016 in response to concerns raised with us about staffing levels and the high use of agency staff as well as staff lacking the knowledge to meet people’s needs safely. Following that inspection, we made a recommendation that the deployment of staff at mealtimes was reviewed in order for people’s nutritional needs to be met promptly and to improve the mealtime experience.

At this inspection, in March 2016, we found sufficient action had not been taken to ensure people received sufficient food and fluid to maintain their health, or in relation to the deployment and availability of staff to ensure people were supported to eat their meals in a timely manner. The home’s overall rating of Requires Improvement made at the October 2015 inspection remains unchanged following this inspection.

While some people’s nutritional needs were being well met, others were not. Care plans identified people’s risk in relation to poor nutritional and hydration. Management and support plans identified the actions required to mitigate these risks. However we found these actions and plans were not always being implemented. For example, where a care plan identified a person should have their food and fluid intake monitored and their weight checked weekly, these actions were not occurring. Some people had not been weighed for several weeks and food and fluid charts were either not being completed or were not completed in full.

Some people had been prescribed nutritional supplements. Their medicine administration records showed these had been given to people, however records were not maintained of how much people had been able to drink of these. It was therefore not possible to ascertain if people were receiving the supplements as prescribed.

At the inspection in October 2015 we were told mealtimes were protected with staff not taking their own breaks to ensure people were supported with their meals. At this inspection we found some staff were taking their breaks during the lunchtime period and some people were not being assisted to eat their meals in a timely manner. For example, we saw one member of staff place a bowl of soup in front of one person and then leave. After 20 minutes another member of staff assisted this person with their soup. There was also a delay in people receiving their main meal as they had to wait until everyone else had received their starter before staff provided the main meal. This had an impact on how much some people had to eat.

Some people did not eat their lunchtime meal and were not provided with anything else to eat other than the routine drink and biscuits and cake during the afternoon. The catering staff were not informed of who had not eaten and had not been asked to provide alternative meals that may have been more appealing or tempting for those people who had not eaten.

One relative told us they were satisfied with the quality, quantity and nutrition of the meals provided but felt their relation was not getting enough to drink.

On the dementia care unit on the first floor there were two dining rooms, one for people who were more independent with their meals and one for those who required support. Over the lunchtime period in this unit, we observed people being supported with their meals individually and in a timely way. People were shown two plates of food to make a choice about what they wished to eat. We saw people given a choice of three desserts and one person said they would like all of them which staff gave them. Some people were being cared for in their rooms and staff were allocated to support these people with their meals.

Following this inspection, the registered manager informed us of the actions that had been and were to be implemented to ensure people’s nutritional and hydration needs would be fully met. This included staff meetings; more thorough reviews and handover reports of people’s needs; more scrutiny of people’s food and fluid intake records and the actions to take should these be insufficient, as well as reviewing the timing of, and support available, during meals. The provider also confirmed there would be no new admissions to the home while they make the necessary changes to ensure people receive safe care and support.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

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

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found:

Is the service caring?

People we spoke with who lived at the home told us that staff were caring and looked after them well. One person told us 'They are very kind here ' all the nurses couldn't be better'. A relative we spoke with said 'I could not imagine anywhere better for (my relative). The staff give her lots of genuine love and affection. '

We observed people being supported to eat their lunch in the dementia unit. We saw people were treated with respect and affection. As an example, we saw one person had been given their meal but were reluctant to eat. We saw a member of staff watch them from a distance and then approach them and encourage them to eat independently. When they did not do this after several prompts the staff member supported and encouraged the person to eat by filling their fork and guiding it to their mouth. We saw the staff member sat with them and made good eye contact while keeping the person's focus on eating. We saw the person responded well to the member of staff who was patient and supported them at their own pace.

This demonstrated to us that the staff were patient and caring towards the people who lived at the home.

On the day of our inspection we saw that it was the birthday of one person who lived at the home. We saw the home's chef had prepared a cake and staff gathered together with the person's family to sing 'Happy Birthday' to them. We saw celebrations were also in hand to celebrate one other person's 40th birthday with them. This told us the home respected and celebrated significant and personal events with people.

Is the service responsive?

We saw that the home responded quickly to changes in people's needs. We saw for example that care plans and assessments were reviewed regularly to identify changes in people's condition. We saw that a GP was called on the day of our inspection to support people who had been unwell overnight.

We saw the home reacted positively to comments and suggestions. At our last inspection in February 2014 we had commented in our inspection report that the main double doors were difficult for a wheelchair user to operate independently. We saw in the home's development plan that this was being actioned with new doors. The home also had regular residents meetings. We saw the minutes of the last meeting where people had identified they would like pasties as an evening meal choice. We saw that this had been actioned. This told us the home responded to people's requests about their care and treatment.

Is the service safe?

People told us they felt safe at the home. One person told us 'Of course I feel safe here. If I didn't I would leave'. Another person told us 'I do feel safe. The staff are lovely and there is always someone here to help if I need it'. A relative we spoke with told us their relation had settled well at the home and had told them they were 'happy and content here. I don't think that would be the case if they were worried about anything. I am sure they would tell me or the staff if they were'.

We saw that risks to people who lived at the home, visitors and staff were assessed regularly. We saw there were regular audits of practice and the competency of the nursing team was assessed by the Registered Manager, for example with medication. Spot checks were carried out by the management out of hours to ensure standards were maintained at all times.

CQC is responsible for monitoring the deprivation of liberty safeguards which applies to care homes. No-one at the home was subject to an authorisation by the Court of Protection, or a Supervisory Body under the Deprivation of Liberty Safeguards. However the home manager was aware that following a recent Supreme Court judgement applications would need to be made to ensure that where people had been deprived of their liberty, through for example locked doors on the dementia unit, this was lawful. Each person had been assessed by the home to see if the new legislation affected them. The Registered Manager had sought advice from the local care trust in relation to how to manage the applications that would be needed and was preparing to make applications. This meant that the provider was acting to ensure that people's rights were protected and that where people were being deprived of their liberty this was in accordance with legislation.

Is the service effective?

We saw that people received effective support to maintain or support their health and wellbeing. As an example, we followed through one person's care plan in relation to nutritional support. We saw that the plan had been actioned with specialist support from the speech and language therapy services. The person had gained weight. This told us the care plan and support had been effective.

A relative we spoke with told us 'I am very happy with (my relative's) care. She is putting on weight, and her face is filling out ' she looks so much better since she came in. She is having her hair done regularly and she always looks well groomed. Sometimes she is up and down, but she is now interacting with people. And she enjoys joining in the singing.'

Another person said of the staff 'They are very good. I need hoisting and help with getting about. They know what they are doing when they help me to move ' I have no complaints'.

Is the service well led?

We saw the Registered Manager of the home was experienced and knowledgeable. Staff we spoke with told us they enjoyed working at the home, and felt they were well supported. They understood who was in charge and their individual roles. Staff told us 'The staff here get access to good training. It's very important for us to work well as a team and we do'. Another staff member said 'I feel very supported, there is always someone here to ask. (Staff member's name) is my mentor and I can ask them anything, I am so very happy to be working here. I really love my job'.

We found that management systems were effective and gave a clear picture of the quality of the service that people experienced.

People we spoke with or their relatives told us they received good care. We saw people being supported well by workers, and engaging in positive relationships. People said 'Nobody really wants to be here. But if they have to come into residential care this is the best place - they couldn't be in a better place than here'. Other people told us Mount Tryon was 'the best home' they had seen, and said 'we are always happy to visit and are always made welcome'.

One person said 'I get out and about quite often and sometimes go swimming', and another that 'I very rarely get bored. There's always a lot going on'. Sensory objects and reminders were situated in the dementia care unit, including objects to touch and hold as well as those to provoke memories.

We found that overall people's medication was managed well, and the home's records were kept up to date and secure. We found that the home was clean and workers understood cleaning and maintenance schedules to keep it so. They had access to equipment to control the risks of cross infection.

However we found we had some concerns over the way people with impaired capacity were involved in making decisions around their care or how other people made decisions on their behalf regarding their care.

Following the January 2013 inspection the provider wrote to us and, in a detailed action plan, described the arrangements that would be put in to place to achieve compliance by the end of March 2013. In April 2013 we reviewed copies of training reports, training plans and quality assurance reports. We found that these documents provided evidence to demonstrate that suitable arrangements were in place for staff to receive appropriate training.

We spoke with one person and two relatives about staffing levels. One relative said there 'could always be more staff' in any care setting but there were enough staff 'most of the time'. The person we spoke with agreed with this opinion and added '95% of the time they're alright'. Another relative said that at the majority of time there were enough staff. They added that 'Things are a lot better.'

At our last inspection in April 2012, 50% (30 of the 60 staff) were up to date with mandatory training. At this inspection we were shown a report which showed that 67% of staff were up to date with mandatory training. We were told that, as part of the New Year budget, training hours had been increased from 14 to 30 hours per week. The manager gave an assurance that the 85% target for training would be met by the end of March 2013.

We reviewed the complaints records and saw that both formal and informal comments and complaints had been recorded. Records clearly showed the action taken. One relative said 'Things have improved greatly.' One person said they took any 'concerns' to the senior nurse and they were 'sorted'.