Archived: Two Rivers Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Staff did not receive regular up to date training and support to complete their work. There were multiple gaps in staff training which the managers and provider were not aware of until we had identified this issue. When something did go wrong the lessons associated were not highlighted to staff to try and prevent something similar happening again. There were multiple ways to share information with staff and multiple places for staff to handover information at the beginning of the new shift. This increased the risk of incorrect information being shared with staff. For example, we found a person had been wrongly named as having had a seizure placing both people at risk. Managers and the provider had not assessed if these ways of sharing information were working correctly. Managers were not checking staff were competent and knowledgeable in all of their work. When managers did complete a competency check it was poorly documented. There was sufficient staff, but they were poorly deployed to promote people's social experiences and well-being. The managers and provider were not assessing if they had enough staff, and they were not considering staff fatigue and ability to provide care tasks and commissioned social time with people effectively during a 12-hour shift.

This service scored 42 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People could not tell us about this.

Staff told us they would raise concerns about people's health needs to a manager. They were aware of new care plans but had not seen these. They were aware of existing historic risk assessments but they not using these. The managers and the provider were not ensuring people had up to date accessible risk assessments and reviews. Managers had recently completed care plans for people but staff were not using these or being trained or supported to do so.

Managers were not effectively assessing, exploring, and reviewing people's needs including their communication needs. We found some staff who knew people well, knew how some people communicated their needs, but managers were not seeking and sharing this information with the other staff.

People could not tell us about this.

Staff were aware of new care plans, prior to this the staff did not have have care plans to follow. They were aware of risk assessments but staff said they were not accessing these or knew where these were located in the home.

The provider did not have a process to ensure people had risk assessments and regular reviews about the care they wanted and needed to receive. No process had been put in place to ensure the new care plans were effective, complete, utilised and understood by staff.

People could not tell us about this.

Staff had shared concerns with the GP when people were unwell. But staff were not all knowledgeable about the risks people faced. Managers had ensured social care professionals had up to date information about people's health needs. But other aspects of people's lives were not being promoted by managers and the provider.

The local authority had significant concerns about the strength of the leadership and culture of the staff team. The local authority were assessing the service twice a week to monitor the associated risks.

The provider had failed to address the poor information held at the service in relation to the risks which people faced, their interests, ambitions, and needs in relation living independently. They did not have tested and effective processes to ensure people moved from one service to another with accurate and current information about themselves.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People could not tell us about this.

Staff could not tell us how or if this happened.

There were no processes to holistically review people's care needs in a person centred way, to look at what could be improved, changed or had worked well. The provider was also not auditing people's care experiences to assure themselves people were receiving good quality care.

People could not tell us about this.

Staff could show us consent to care forms which had been completed following a best interest process. One member of staff told us a key improvement since the last inspection was they now asked people what they wanted to wear each day. However, for more complex forms of consent and restrictions on people's freedoms, staff were unable to comment on. Managers and the provider were not assessing staff's competency in this area of their work.

The managers and leaders had completed best interest processes when considering consent to care and to live in the supported living services. But, they had not ensured these best interest processes were documented according to best practice. The provider was not auditing this aspect of people's care to ensure their staff promoted people's right to consent. The provider was not advocating for people's rights by ensuring processes were in place and actions were taken by managers when individuals could not consent to live in the supported living services.