CQC report explained · a residential care home
What the CQC found at Turret Villa Retirement Home
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 2024
Rated Requires Improvement; inspectors found unsafe medicines management, gaps in risk checks and training, and weak quality monitoring.
This was an unannounced focused inspection on 17 and 18 January 2024. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
The home had enough staff, people were protected from abuse, the building was maintained, and people generally felt cared for. However, medicines were not always stored, recorded or disposed of safely. Risk-control actions were not always followed, and some staff training was out of date.
The home was rated Requires Improvement overall for the areas inspected: Safe, Effective and Well-led. The overall rating fell from Good at the previous inspection. Caring and Responsive were not inspected during this visit, so their previous ratings carried over.
Enough staff
Inspectors found enough staff to meet people's needs and keep them safe. People said staff responded when they used their call bells.
“There were enough staff on duty to care for people safely.” from the report
Protection from abuse
Staff understood how to protect people from poor care and abuse. Safeguarding incidents were investigated and reported to the relevant authorities.
“People were safeguarded from the risk of abuse.” from the report
Healthcare support
People could access healthcare services when needed. Staff made timely referrals and followed advice from healthcare professionals.
“People were supported to access healthcare services whenever they needed support.” from the report
Supportive culture
People enjoyed living at the home and felt listened to. Staff described the management team as supportive.
“There was a positive culture in the service. Staff said the management team were supportive.” from the report
Medicines were not consistently safe
seriousSome medicines were insecure, out of date or not disposed of promptly. Stock records were wrong, and medicines audits were incomplete.
“Medicines were not always managed safely. Medicines were not always stored appropriately or disposed of safely.” from the report
Risk actions were missed
seriousSome planned actions to reduce risks were not happening or were not recorded. This included weighing people at risk of malnutrition and repositioning someone at risk of pressure sores.
“People had assessments in place which included actions to reduce risks, but the actions were not taking place.” from the report
Training was out of date
seriousSeveral staff were overdue training in areas including safeguarding, medicines, fire safety and end-of-life care. The training policy was also out of date.
“Multiple staff members were out of date for training courses including safeguarding, medicines, health and safety, fire safety, end of life and learning disabilities training.” from the report
Consent records were incomplete
seriousMental capacity assessments and best-interest decisions were not always recorded for restrictions such as movement sensors or wheelchair restraints.
“Mental capacity assessments and best interest decisions were not always in place.” from the report
- 01What changes have been made to medicine storage, controlled drugs, stock checks, disposal and staff competency checks?
- 02How are you now making sure weekly weights, food and fluid monitoring, and repositioning plans are completed and reviewed?
- 03Which staff training is now up to date, especially medicines, safeguarding, fire safety and end-of-life care?
- 04How are mental capacity assessments and best-interest decisions recorded for movement sensors, wheelchair restraints and other restrictions?
- 05How will your quality checks show that incidents, medicines problems and care-plan issues are identified and corrected?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 17 February 2024 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 2020
Turret Villa Retirement Home was rated Good, improving from Requires Improvement, although inspectors found minor medicines recording issues and staffing pressure at busy times.
This was a focused inspection on 17 July 2020. One inspector and an expert by experience spoke with people, relatives, staff and health professionals. They also reviewed care, medicines, safety and management records.
The home was rated Good for Safe, Responsive and Well-led. Inspectors found improved risk assessments, safer medicines management, better care plans, infection control measures and systems to monitor quality. People and relatives spoke positively about the care and management.
The inspection followed an earlier rating of Requires Improvement and two previous breaches. Inspectors found that action had been taken and the home was no longer in breach. Some minor issues still needed attention, including medicines records, detailed care plan reviews and checks carried out for the provider.
Improved risk management
Risk assessments had improved and gave staff clearer information about individual risks and how to reduce them.
“Risk assessments had improved. These now set out the individual risks to each person and the strategies used to minimise these.” from the report
Better care planning
Care plans had become more detailed and gave staff clearer guidance about personalised care.
“Care plans were now more detailed and guided staff on how to provide person-centred care.” from the report
Infection control
The home had infection prevention systems, staff used protective equipment safely and there had been no known Covid-19 cases at the time.
“Staff used personal protective equipment (PPE) such as masks, gloves and aprons, effectively and safely.” from the report
Positive culture
People, relatives and staff spoke positively about the management. Inspectors found a person-centred culture and evidence of improvements to the building and records.
“There was a positive, person centred culture at the home. People and relatives said the care was personalised and individual choices were respected.” from the report
Medicines records
minorInspectors found several minor recording problems with medicines. The manager said these would be dealt with immediately.
“We identified several minor recording issues which the registered manager told us would be immediately addressed.” from the report
Busy staffing periods
needs fixingStaff said some duties took them away from spending time with people and that some shifts were particularly busy. The manager was changing shift times and recruiting kitchen assistants after the inspection.
“Care staff supported the cook to wash and dry dishes. Staff explained that this duty, sometimes took them away from spending time with people.” from the report
Care plan reviews
minorAlthough care plans had improved, inspectors asked the manager to make sure every part of each plan was reviewed.
“We discussed with the registered manager about refining the care plan review documentation to ensure each area of the care plan was reviewed.” from the report
Provider oversight
minorIt was unclear what checks the provider carried out on the home. The manager said future provider checks, monitoring visits and meetings would be recorded.
“It was not clear however, what checks were carried out on behalf of the provider.” from the report
- 01What medicines recording issues were found, and how do you now check that medicines records are complete?
- 02Have the changed shift times and extra kitchen support reduced pressure during busy periods?
- 03How do you make sure every area of each person's care plan is reviewed and kept up to date?
- 04What checks does the provider now carry out, and where are the monitoring visits and meetings recorded?
This was a focused inspection of Safe, Responsive and Well-led; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 22 August 2020 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 Turret Villa Retirement Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Turret Villa Retirement Home →
- August 2020Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Turret Villa Retirement Home →
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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