Archived: Troutbeck Care Home

Updated 6 February 2024

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.

Inspection team

The inspection team consisted of 3 inspectors, a pharmacist inspector 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.

Troutbeck Care Home 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. Troutbeck Care Home 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was no registered manager in post. A new manager had started four weeks prior to the inspection and had plans to register with CQC.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We met with key stakeholders such as the local authority to fully understand their concerns and to include these in planning for our inspection.

During the inspection

Over the course of our three visits we reviewed the care records for 15 people. Multiple records relating to medicines and the management of the service were also reviewed.

Updated 6 February 2024

About the service

Troutbeck Care Home is a nursing home providing personal and nursing care to up to 52 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 38 people using the service.

People’s experience of the service and what we found:

Staff delivered poor care and treatment to people, which put them at risk of significant harm. The service did not always properly assess and plan for risks, which meant measures were not in place to reduce or minimise them.

Staff were not always aware of people’s care needs. This meant we could not be assured people were receiving appropriate care which was safe for them.

Staff did not support people to have enough to eat and drink. At the time of our inspection 20 people had suffered unintentional weight loss in the service at the time of our inspection. The service had not addressed this robustly to protect people from malnutrition and dehydration.

Staff did not take action, where safeguarding concerns were evident. They failed to protect people from incidents where people were repeatedly assaulted by another person using the service and had accepted this as the norm.

The building was not safely maintained, and the provider had failed to take prompt action to address fire safety concerns, which meant people were at risk of harm in the event of a fire.

People did not receive support from staff in a timely way and people made negative comments about the time it took for staff to respond to their needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People’s dignity and respect was compromised in the service and people were not provided with person centred care. There was a poor culture among the staff team at all levels, with some staff displaying a disregard for people’s health and welfare.

People were at risk of social isolation, boredom and disengagement because the service did not ensure that they had sufficient sources of meaningful engagement or stimulation.

The provider has failed to operate the service in a way which is safe, effective, caring, responsive and well-led over a period of 9 years. The service has only been compliant with fundamental standards and regulations at one of 9 inspections since 2014.

Quality assurance systems had been ineffective in taking prompt action in response to shortfalls identified. This meant people had continued to receive poor care and be put at risk of harm.

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 3 September 2019).

Why we inspected

The inspection was prompted in part due to concerns received about nutrition, sexual safety, wound care and staffing levels. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to person centred care, dignity and respect, consent to care and treatment, premises and equipment, safe care and treatment, nutrition and hydration, safeguarding, staffing and good governance.

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

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.