What the CQC found at Mount Tryon

Staffing levels had improved and agency staff were no longer being used. People, relatives and some staff noticed a more settled atmosphere.

“Staffing numbers within the service had improved and agency staff were no longer in use.” from the report

The home was no longer in breach of the medicines part of Regulation 12. Storage, disposal, staff training and competency checks were in place, although some records still needed improvement.

“Enough improvement had been made at this inspection and the provider was no longer in breach of this part of regulation 12.” from the report

Staff had safeguarding training and could explain how to recognise and report abuse. People said they felt safe with staff.

“The provider ensured staff received training on how to safeguard people and staff we spoke with were able to identify different types of abuse” from the report

Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including use of protective equipment and supporting visitors.

“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report

Accidents and incidents were recorded and reviewed for patterns. Staff understood the steps to take after a fall or other incident.

“Accidents and incidents were reported and monitored by the service management to identify any patterns or trends.” from the report

Records gave conflicting instructions about repositioning and did not always show that people had been repositioned as needed. This could put people at risk of skin damage.

“This placed people at risk of skin damage due to inconsistency in documentation to guide staff.” from the report

Fluid records were sometimes completed incorrectly or not checked, and concerns about low fluid intake were not always escalated. Nutrition records were also incomplete.

“Systems had failed to identify staff had incorrectly completed records.” from the report

Inspectors found no specific care plan or risk assessment for one person using oxygen, and no care plan for another person using a urinary catheter. This meant staff did not have clear written guidance.

“One person required oxygen as part of their care delivery. We identified the person had no oxygen signage on their door, no specific care plan or risk assessment had been produced” from the report

The home's audits and governance systems had not identified the repeated problems with care records, fluid monitoring and some medicines records. This was a continued breach.

“Governance systems implemented had not identified the continued issues around topical medicine administrations, cool storage temperature checks or pain relief patch management.” from the report

Although staffing had improved, some staff said numbers were still low at times, especially during sickness. Some people said they were rushed, and staff in the upstairs dementia area wanted more support.

“Others felt staffing numbers were still low at times, especially when there was unplanned sickness.” from the report