Mount Tryon

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At the previous assessment the service was in breach of the regulation in relation to people’s safe care and treatment as risks had not been effectively mitigated and medicines had not been managed safely. At this inspection we found improvements had been made. There were now effective systems in place to ensure all risks to people were identified and mitigated, and to ensure people were safely supported with their medicines.

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

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents were documented by staff and promptly investigated by the registered manager to identify any areas of learning or possible improvement. Records showed changes had been made to staff practices and additional training provided because of learning identified.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt and changes made to improve safety. Accidents and incidents were documented by staff and promptly investigated by the registered manager to identify any areas of learning or possible improvement. Records showed changes had been made to staff practices and additional training provided because of learning identified.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. Information was shared promptly and effectively when people moved between services. This included details of their specific needs, wishes and expectations to help ensure these preferences were constantly met.

The provider worked with people and healthcare partners to understand what being safe meant to individuals and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People told us they were safe at Mount Tryon and said, “It’s not a boisterous place”. Relatives commented, “We are confident that [my relative] is well looked after and safe”, “We are very confident that [our relative] is well looked after and safe because the staff are so competent and on top of everything” and “Mount Tryon has given [my relative] the ability to feel safe and secure in [themselves] as help on hand 24/7.” Staff were clear on their responsibilities for ensuring people were protected from all forms of abuse. They were confident any safety issues they reported would be investigated. Information on how to make safeguarding referrals was displayed in the staff room and records showed the registered manager had made appropriate safeguarding alerts. Managers and staff had a good understanding or the requirements of the Mental Capacity Act (MCA). Relatives and involved professionals had been appropriately involved in best interest decision making. Where necessary applications for the authorisation of restrictive practices had been made to the local authority under the Deprivation of Liberty Safeguards (DoLS).

The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises and equipment were well maintained. Necessary checks and audits were completed by appropriately skilled contractors to ensure the environment, and all available equipment was safe to use. The provider completed regular environmental audits to ensure any faults identified were promptly resolved.

The provider and registered manager had identified there was limited communal space on the first floor and that this was impacting on people’s wellbeing. As a result, plans had been developed to provide a second lounge area on the first floor and these works were due to be completed in 2025.

The light in one person’s room was operated by a switch in the corridor which was accessible to anyone passing. A relative told us this was having an adverse impact on their family member. We raised this with the registered manager who spoke with the person and took immediate action to resolve the issue.

The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. The premises and equipment were well maintained. Necessary checks and audits were completed by appropriately skilled contractors to ensure the environment, and all available equipment was safe to use. The provider completed regular environmental audits to ensure any faults identified were promptly resolved The provider and registered manager had identified that there was limited communal space on the first floor and that this was impacting on people’s wellbeing. As a result plans had been developed to provide a second lounge area on the first floor and these works were due to be completed in 2025. The light in one person’s room was operated by a switch in the corridor which was accessible to anyone passing. A relative told us this was having an adverse impact on their family member. We raised this with the registered manager who spoke with the person and took immediate action to resolve the issue.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean throughout and there were procedures to ensure all areas of the service were regularly cleaned. Staff understood how respond to infection control risks and the service’s laundry well organised and appropriately equipped.

People felt the service was clean. One person told us, “It’s very clean. It's a wonder there are any corridors left, they are always cleaning them!.” Relatives shared people’s views and told us, “It is clean and pleasant” and “Staff are forever around cleaning. If I mention that [My relatives] bed needs changing, they deal with it quickly, very responsive.”

Hand wash facilities were available to staff throughout the service and personal protective equipment (PPE) was available when required. Staff said, “PPE is available in all the rooms”. This helped to reduce the risk of infections being spread around the service, and helped to keep people safe from the risk of harm.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they received their medicines when they were supposed to, and records showed medicines had been given as prescribed. One person told us, “They help me with my drugs, they have taken responsibility for them now.”

A relative told us, “They are very good with the medication. The nursing care is very good.” Another relative said, “[My relative] is on a lot of medication and it is well managed by the home and the GP.”

People’s medicines were regularly reviewed and care plans contained detailed guidance for staff on the use of any ‘As required’ medicines. Staff had completed medicines training and had their competency regularly assessed.

Medicines were administered, stored and disposed of safely. Controlled drugs were stored and recorded appropriately. Systems were used to help ensure people’s pain relief needs were met at all times, including at the end of their lives.

Medicines audits were regularly completed and any errors used as opportunities for learning and improvement. There were systems to ensure staff were promptly informed of significant changes to people’s medicines or care needs. This helped to ensure people’s needs were met in a timely manner.