CQC report explained · a nursing home
What the CQC found at Torrwood Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and guidance was in place. Medicines, infection control, safeguarding and environmental checks were found to be managed safely, although staffing levels had fluctuated during the pandemic.
- Effective?
- Good
- People's needs were assessed, staff were trained and consent and best-interest decisions were documented. Records of food and fluid intake were variable because the home did not use monitoring charts.
- Caring?
- Good
- Staff were warm, respectful and discreet. People were supported to make choices and maintain their dignity and independence.
- Responsive?
- Good
- Care plans reflected people's physical, emotional, social and communication needs. People had activities, support to contact relatives and support for their spiritual needs.
- Well-led?
- Good
- The provider had audits, care planning systems and a service improvement plan. However, audits had not identified that records for repositioning and mattress settings were unclear.
What inspectors found, September 2021
Rated Good; inspectors found kind, personalised care and clear improvements, but records for repositioning and food and fluid intake needed attention.
This was an unannounced inspection on 17 August 2021. Inspectors spoke with four people using the service, one relative and eight staff. They reviewed care records, medicines records, recruitment files, training information and quality checks.
The home was rated Good overall, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and well looked after. Inspectors saw warm, respectful care and found that people's needs, choices, dignity and independence were generally supported.
The home had improved since the previous inspection, which was rated Requires Improvement and had three breaches of regulation. The provider was no longer in breach. Inspectors did identify weaknesses in recording repositioning and food and fluid intake, and the repositioning system was changed after the inspection.
Kind and respectful care
Inspectors saw warm and friendly interactions. People appeared relaxed and comfortable with staff.
“We observed staff were warm and respectful when speaking to people, and people were relaxed and comfortable with the staff.” from the report
Personalised care
Care plans included people's preferences, routines, needs and areas of independence. Staff used this information to provide individual support.
“Care plans reflected people's physical, mental, emotional and social needs.” from the report
Good safety arrangements
Risks, medicines, infection control and the environment were checked. Accidents and incidents were reviewed and actions were taken.
“The provider had a comprehensive system of checks to manage the safety of the environment.” from the report
Family contact and activities
The home supported visits, video calls and communication with relatives. It offered activities and made efforts to include people who could not join group activities.
“People were encouraged to maintain contact with friends and family.” from the report
Repositioning records
needs fixingThe system for recording position changes and mattress settings was unclear. This made it difficult to confirm that people were repositioned at the right intervals and that air mattresses had the correct settings.
“The system in place for recording and monitoring position changes and mattress settings was not clear.” from the report
Staffing pressure
needs fixingStaffing levels had fluctuated during the pandemic. One staff member said the home could not always obtain agency cover and staff worked extra shifts.
“Staffing levels had fluctuated since the start of the pandemic.” from the report
No recorded complaints
minorThe home had not recorded any complaints since the previous inspection. The manager thought this might have been linked to the pandemic and visiting restrictions.
“Since the last inspection the service had not recorded any complaints.” from the report
- 01What new system is now used to record repositioning and mattress settings, and how is it checked?
- 02How do you monitor whether each person is eating and drinking enough without food and fluid monitoring charts?
- 03What are the current staffing levels, and how do you cover sickness, vacancies and other absences?
- 04How can families raise a concern or complaint, and how will it be recorded and followed up?
- 05How are families involved in care plan reviews and decisions about their relative's care?
This was an unannounced planned inspection based on the previous rating and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 2 September 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.
What inspectors found, November 2019
Requires Improvement; inspectors found kind care and enough staff, but serious gaps in safety, consent, records and quality checks.
This was an unannounced inspection on 1 and 2 October 2019. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
People were generally treated with kindness, dignity and respect. Staffing levels were not a concern, medicines were mostly managed safely, and people had access to activities, healthcare and community links.
However, cleaning and infection control were poor in some areas. Risk assessments and care records were incomplete or out of date. The Mental Capacity Act was not always followed when decisions were made for people. The service was rated Requires Improvement overall, with the same rating for Safe, Effective, Responsive and Well-led. Caring was rated Good. This means there was limited assurance about safety and an increased risk that people could be harmed.
Kind and respectful care
People said staff were caring, patient and respectful. Inspectors found that people were involved in everyday choices and supported to remain independent.
“People told us staff protected their dignity, independence and treated them with respect.” from the report
Staffing and safeguarding
People, relatives and staff generally felt there were enough staff. Recruitment was described as safe, and staff knew how to raise safeguarding concerns.
“Staff were employed in sufficient numbers to keep people safe.” from the report
Medicines
Inspectors found that medicines were ordered, given and disposed of safely. Records for medicines were accurate, including medicines needing extra controls.
“People's medicines were ordered, administered and disposed of safely.” from the report
Activities and relationships
People could join activities, spend time with others and receive support from volunteers and a music therapist. The home also linked with schools and community groups.
“The service employed an activity co-ordinator, a volunteer co-ordinator and a music therapist.” from the report
Poor infection control
seriousSome toilets, sinks, kitchenettes and treatment areas were dirty. Cleaning cloths were reused in food preparation areas, and staff were unclear about who should do different cleaning tasks.
“People were not assured to be protected from cross contamination.” from the report
Risks were not always assessed
seriousSome choking, nutrition, mobility and falls risks were not fully assessed or kept up to date. Washing-up liquid was also left where people living with dementia could reach it.
“People at risk of choking were not risk assessed.” from the report
Consent decisions
seriousThe Mental Capacity Act was not always followed. DoLS applications were made for some people who had capacity, and a best-interests decision was not recorded for one person's diet.
“The MCA was not always applied correctly.” from the report
Incomplete and impersonal records
seriousCare plans and daily records did not always explain what mattered to each person or give staff clear, current guidance. This could make it harder for new or temporary staff to provide the right support.
“Not ensuring people's records were complete is a breach of Regulation 17 the Health and Social Care Act 2008 (Regulated Activities) 2014.” from the report
Checks did not find problems
needs fixingThe home had audits, but they had not identified the infection control, consent, risk and record-keeping problems found during the inspection.
“these did not identify the issues we found on inspection and therefore the quality of the service had not been maintained.” from the report
- 01What has been done to improve cleaning standards and stop cross contamination, and who is now responsible for each cleaning task?
- 02How are choking, falls, nutrition and other risks now assessed, reviewed and acted on?
- 03How do you check that Mental Capacity Act assessments, best-interests decisions and DoLS applications are correct and up to date?
- 04How have care plans and daily records been changed so they include each person's history, preferences, communication needs and current support?
- 05What evidence can you show that your audits now identify problems before they are found by inspectors?
This was an unannounced planned inspection covering the home, the care provided and all five CQC questions; the previous Good overall rating changed to Requires Improvement. This explanation was written from the published report of 30 November 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 Torrwood Care Centre
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 10 November 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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