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Torrwood Care Centre Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 30 November 2019

Torrwood Care Centre (“Torrwood”) is a residential care home providing personal and nursing care to 76 people aged 65 and over at the time of the inspection. The service can support up to 82 people.

Torrwood accommodates people across three separate units, each of which has separate adapted facilities. Two of the units specialise in providing care to people living with dementia.

People’s experience of using this service and what we found

People told us they were supported by staff who were caring. People told us staff protected their dignity, independence and treated them with respect.

Torrwood had not been able to maintain the quality of the service since the last inspection. We found people’s records lacked some essential detail. Records were not always complete and from initial assessment to writing the full care plan, details of people’s past and present lives were not used to inform their current care and records.

All risks associated with people’s needs had not been identified and/or records had not been updated to include the up to date details.

We have recommended the provider reviews their initial assessment recording to ensure people’s needs are fully assessed and personalised and, the provider review their recording of people’s health events and health professional’s involvement to ensure they are complete and contemporaneous.

The Mental Capacity Act 2005 was not always applied correctly. People were not always supported to have maximum choice and control of their lives and staff did not always 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.

The service used signage on important rooms to help people living with dementia identify them. For example, bathrooms and toilets. The décor of the service did not aid moving around independently. We have recommended the provider consult with a dementia specialist to gain advice on the décor.

People were not protected by good infection control practices. Staff were confused as to whose role different cleaning tasks were. This meant people’s environment and health were being put at risk.

People, relatives and staff were supportive of the management of the service. Systems were in place to review the quality of the service. However, we found these had not identified the issues found on inspection.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 11 March 2017). Safe however, was rated as Requires improvement. This was due to concerns raised about staffing levels about which we gave a recommendation for the provider. Staffing levels were not a concern on this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvement. Please see the safe, effective, responsive and well-led sections of the full report.

The overall rating for the service has changed from Good to Requires improvement. This is based on the findings at this inspection.


We have identified breaches in relation to how the service ensured good infection control, people’s capacity to consent to their care, people’s records were incomplete and ensuring the quality of the service at this inspection.

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

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 30 November 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 30 November 2019

The service was not always effective.

Details are in our effective findings below.



Updated 30 November 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 30 November 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 30 November 2019

The service was not always well-led.

Details are in our well-Led findings below.