CQC report explained · a nursing home
What the CQC found at Richmond Village Witney
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found safe medicines and kind support, but serious gaps in records, staffing and leadership.
This was an unannounced focused inspection on 15 December 2022. Inspectors reviewed Safe, Effective and Well-led only. They spoke with people, relatives, staff and healthcare professionals, observed care, and checked care records, medicines records, staff files and management records.
The home was rated Requires Improvement overall. Safe and Effective were rated Requires Improvement. Well-led remained Requires Improvement. Care records were incomplete, and records did not always show that important care, such as position changes and checks, had happened. Staffing on the nursing unit was stretched, with staff reporting that they struggled during busy periods.
Inspectors also found positive areas. Medicines were managed safely, the home was clean, people were supported with food and drink, and staff understood the Mental Capacity Act. A new manager had started an improvement plan, but the home had experienced several managers and was not yet able to show consistent improvement.
The report says the provider breached Regulation 17 about good governance because people's records were not always complete or up to date. CQC asked for an action plan and said it would monitor progress with the provider and local authority.
Safe medicines
People received their medicines as prescribed. Inspectors found accurate administration records and safe storage.
“People received their medicines as prescribed and the service had safe medicine storage systems in place.” from the report
Clean environment
The home was clean and fresh-smelling. Inspectors found extra cleaning schedules and good infection prevention arrangements.
“We found the environment was clean and smelt fresh.” from the report
Support with meals
Inspectors saw people receiving dignified support with food and drinks, including in their rooms when they preferred.
“During lunchtime, people were supported by attentive staff.” from the report
Understanding of capacity law
Staff understood how to support people who might lack capacity. Inspectors found capacity assessments and best-interest decisions were completed when needed.
“Staff had a particularly good understanding of when the principles of the Mental Capacity Act should be applied.” from the report
Incomplete care records
seriousRecords did not always show that required position changes, bedrail checks, oral care or mattress checks had taken place. This meant inspectors could not be assured that care was consistently delivered.
“Systems had not been established to maintain accurate and complete records. This placed people at risk of harm.” from the report
Staffing pressure
needs fixingThe nursing unit was short-staffed on the inspection day, and staff said they often struggled during busy periods. People and relatives reported waiting for help.
“We found inconsistency in leadership had resulted in poor staff retention, high staff turnover and therefore increased use of agency staff.” from the report
Unstable leadership
needs fixingThe home had struggled to appoint and retain managers over several years. This affected staff morale, support, retention and people's care.
“The home had struggled to appoint and retain managers for the past 5 years.” from the report
Nutrition referral not followed up
needs fixingOne person at high risk of weight loss had lost significant weight. Although a referral to a nutritionist was made, the home had not checked whether it had been received or reviewed.
“However, no one had followed up to check if the referral had been received or reviewed.” from the report
Supervision gaps
minorStaff said they had not received formal supervision or appraisals for some time. The new manager had started arranging supervision.
“Staff told us they had not had formal supervisions and appraisals mainly due to inconsistency in leadership.” from the report
- 01What action has been completed to ensure position changes, oral care, bedrail checks and mattress checks are recorded at the time they happen?
- 02How many staff are planned for the nursing unit on each shift, and how do you cover sickness or other unexpected absences?
- 03How much agency staff is currently being used, and how are you maintaining continuity of care?
- 04What progress has been made with the improvement plan for care records and staff supervision?
- 05How do you follow up nutrition and other healthcare referrals so that no referral is missed?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2019
Richmond Village Witney was rated Good overall, but inspectors found leadership and staff supervision needed improvement.
Inspectors visited without notice on 4 December 2018. They spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records, staff files, complaints, incidents and quality checks.
The home was rated Good for safe, effective, caring and responsive care. People told inspectors they felt safe and were treated with kindness and respect. Inspectors found enough staff, safe medicines practice, suitable training and a good range of activities.
The home was rated Requires Improvement for being well-led. There was no registered manager at the time, leadership had been inconsistent, and staff supervision and appraisal records were not up to date. People's care records were also not always complete or reviewed, although the home had identified these issues and was working on them.
The overall rating of Good means the inspection found the home provided a good standard of care overall. It does not mean every part of the service was without problems. A new manager had been appointed to start in January 2019.
Safe medicines
Inspectors saw medicines being given as prescribed. Records showed when medicines had been given or not taken, with reasons recorded.
“People received their medicines as prescribed and the home had safe medicine storage systems in place.” from the report
Kind and respectful care
People said staff were kind and listened to them. Inspectors saw staff protecting privacy, using preferred names and encouraging independence.
“Throughout our inspection, we observed many caring interactions between staff and the people they were supporting.” from the report
Activities and social life
People had access to activities, outings and events. Staff also offered individual contact to people who did not want to join group activities.
“People had access to a full programme of activities which included seated exercises, Time for Tea sessions on, Christmas fayres.” from the report
Quality checks
The provider had audits covering areas such as medicines, infection control, catering and care plans. Inspectors said these were being used to support improvement.
“Quality assurance systems were operated effectively and used to drive improvement in the service.” from the report
Inconsistent leadership
needs fixingThere was no registered manager when inspectors visited. People, relatives and staff said changes in leadership had affected how the home was run, although they also reported recent improvements.
“Inconsistences in leadership affected improvement of the home.” from the report
Staff supervision records
needs fixingSupervision and appraisal records were not always current or completed according to the provider's policy. The clinical lead had started to address this.
“We also found staff supervisions and appraisals records were not up to date and had not been completed in line with the provider's policy.” from the report
Care records
minorSome care plans were incomplete or had not been reviewed. Inspectors said staff knew people well and the shortfalls posed minimal risk at the time.
“People's care plans were not always complete and some had not been reviewed.” from the report
Staff turnover
minorPeople and relatives reported high staff turnover and past reliance on temporary staff. Inspectors found staffing had improved and regular agency staff were being used to support continuity.
“There has been a big turnover of staff and there was a time that many of them were temporary” from the report
- 01Has a registered manager now been appointed, and how long have they been in post?
- 02Have all staff supervision and appraisal records been brought up to date?
- 03Have all care plans been completed and reviewed, and how often are they checked now?
- 04What is the current level of staff turnover and how often are agency staff used?
- 05What changes have been made to make the dementia unit easier for people to navigate?
This was an unannounced inspection of the whole care home, covering all five CQC questions and the overall quality of care. This explanation was written from the published report of 5 January 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Richmond Village Witney
3 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- January 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2017
Registered with the Care Quality Commission on 12 January 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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