CQC report explained · a nursing home
What the CQC found at Torr Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staffing had improved, call bells were answered promptly, risks were identified and medicines were managed safely. The home still had some difficulty recruiting nursing staff.
- Effective?
- Good
- Staff had suitable training and skills, and people's needs were assessed. Food and drink monitoring records were not consistently completed or accurate.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. Staff knew people's preferences and supported choice, privacy and independence.
- Responsive?
- Good
- Care plans gave staff clear guidance and were reviewed. Activities and family visits were available, although a vacant activities post limited some communal activities.
- Well-led?
- Requires improvement
- Audits and management arrangements had improved, but staff in Belltor felt isolated and lacked regular support from their manager. Further improvement was needed in leadership and oversight.
What inspectors found, November 2022
Rated Good overall, but well-led Requires Improvement and inspectors found gaps in food and drink monitoring and support for some staff.
This was an unannounced comprehensive inspection on 8 September 2022. Inspectors spoke with people, relatives, staff, managers and health professionals. They reviewed care plans, medicine records, staffing rotas, call bell records, audits and safety documents.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found improved staffing, safe medicines management, suitable staff training, kind care, personalised care plans, activities and support for family visits. People told inspectors they felt safe and relatives were generally positive about the care.
The home was rated Requires Improvement for Well-led. Management systems had improved, but staff in the Belltor unit said they felt isolated and had limited support. Food and drink records were not always accurate, and the Belltor unit had limited communal space. The overall rating improved from Requires Improvement at the previous inspection.
Improved staffing
Planned staffing levels were routinely achieved and call bells were answered promptly. Agency staff were used infrequently at the inspection.
“Staff responded promptly to people's requests for support.” from the report
Safe medicines
Medicines were stored, administered and audited safely. Staff responsible for medicines had completed training and competency checks.
“Medicines were managed safely, and people received their medications as prescribed.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed compassionate support and found that people's dignity, choices and independence were respected.
“People were supported and encouraged to remain as independent as possible.” from the report
Personalised care
Care plans contained clear information about people's individual needs and were reviewed with relatives involved.
“People's care plans were sufficiently detailed and gave staff clear guidance on how to meet people's individual support needs.” from the report
Improvements since the last inspection
The home had improved staffing, training, risk management, medicines management and governance. The overall rating rose from Requires Improvement to Good.
“At this inspection we found improvements had been made and the services' overall rating is now good.” from the report
Food and drink records
needs fixingRecords intended to monitor food and fluid intake were not consistently completed and did not accurately show what people had received. Inspectors made a recommendation for improvement.
“These records had not been consistently completed and did not provided accurate information about how much food or drinks people had received.” from the report
Support for Belltor staff
needs fixingStaff in Belltor said they felt isolated and received limited support from the manager based in another unit. Inspectors made a recommendation about leadership and support.
“However, staff in the Belltor unit, physically located next to Torr House but managed from Glentor located approximately 100m away, told us they felt isolated and received limited support from their manager.” from the report
Limited communal space
needs fixingBelltor had only a small lounge and dining area for 12 people, limiting people's choice of where to spend time. Planned building work had been delayed but the cause of the delay was resolved shortly after the inspection.
“This meant people had limited choice over where to spend time as there was insufficient communal space available for the twelve people currently living in Belltor.” from the report
Recruiting nurses
minorThe home continued to have difficulty recruiting additional nursing staff. It had introduced lead care practitioner roles, with nurse support available from another unit.
“The service continued to experience some difficulties in recruiting nursing staff.” from the report
- 01How are you checking that food and fluid records are completed accurately for people who need monitoring?
- 02What has changed to make sure Belltor staff receive regular support and visible management?
- 03When will the planned additional communal areas in Belltor be completed?
- 04How are lead care practitioners supported by nurses, particularly when people need nursing care?
- 05How are activities being provided while an activities coordinator post is vacant?
This was an unannounced comprehensive inspection covering all five key questions and infection prevention and control, with records and feedback reviewed during and after the visit. This explanation was written from the published report of 10 November 2022 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, August 2021
Rated Requires Improvement, with Inadequate leadership; inspectors found serious problems with staffing, care records, medicines and oversight.
This was an unannounced, focused inspection of the home on 10, 11 and 13 May 2021. Inspectors looked only at Safe and Well-led, including infection control. They spoke with people, staff and managers, and checked care plans, medicines records, staffing records and quality audits.
Inspectors found that people sometimes waited a long time for help with toileting, meals and call bells. Staffing levels did not reflect people's needs. Some staff lacked essential training, care records did not always explain people's risks, and medicines were not always recorded or managed safely.
Leadership and monitoring were rated Inadequate. The home did not have effective systems to identify problems, act on people's feedback or check the quality and safety of care. The overall rating fell from Good at the previous inspection to Requires Improvement.
Infection control
Inspectors were assured that infection prevention measures covered visitors, testing, PPE, social distancing, admissions and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe recruitment
The home carried out DBS checks and kept records confirming nurses' professional registration.
“Staff were recruited safely. Disclosure and Barring Service (DBS) checks were carried out to ensure those employed were suitable to work in the sector.” from the report
Safeguarding awareness
People said they felt safe, and staff could explain what to do if they suspected abuse or neglect.
“Staff had received training in safeguarding and spoke confidently about what action to take if they were concerned someone was being abused mistreated or neglected.” from the report
Long waits for help
seriousThere were not enough staff to meet people's needs. Call bells went unanswered for long periods, and this affected people's wellbeing.
“Call bell logs from March to May 2021 showed some people had waited up to 50 minutes or over an hour for support.” from the report
Incomplete staff training
seriousNursing staff had not completed essential clinical training. Only eight of 67 staff had completed dementia training despite the home adding specialist dementia beds.
“The providers training records detailed that only eight out of 67 staff had completed dementia training.” from the report
Care risks not recorded
seriousCare plans did not always describe important needs, such as catheter care, oral suction, specialist bowel support or bed-rail risks. Food, drink and repositioning records were also inconsistent.
“Risks relating to people's care were not always recorded. We did not find evidence that people had come to harm.” from the report
Medicines records
seriousRecords did not reliably show that creams were applied. Allergy information was inconsistent, and guidance for some medicines was not detailed enough for agency nurses.
“Medicines were not always safely managed. This is a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak oversight
seriousAudits failed to identify the problems found by inspectors. The home also did not consistently seek and act on feedback from people or staff.
“There were ineffective governance systems in place to assess, monitor and improve the quality and safety of service.” from the report
- 01What has changed since the inspection to make sure call bells are answered promptly, and can you show us recent call bell records?
- 02How many staff have now completed dementia and essential clinical training?
- 03How do you check that creams, other medicines and allergy information are recorded correctly?
- 04How are individual risks, including bed rails, eating and drinking, skin care and specialist clinical needs, recorded and checked?
- 05What action has been taken to meet the CQC condition on good governance and the staffing warning notice?
This was a focused inspection of Safe and Well-led at Torr Home only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 5 August 2021 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 Torr Home
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Requires improvementSafe: Requires improvementWell-led: Inadequate
- March 2021Inspected but not ratedSafe: Inspected but not rated
- September 2020Goodstayed GoodSafe: GoodWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
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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