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 do 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 this, and the lessons associated were not highlighted to staff to try and prevent something similar happening again. There was no documented process to record staff handover at the beginning of the new shift, so managers and the provider could not be assured correct information about people, especially if someone had been unwell etc was being handed over to staff. 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 social time with people effectively during a 12 hour shift. There was not a culture of staff being aware of when people’s freedoms were being restricted. Managers and the provider were not reviewing these to check if people were being overly restricted and if something could be done to reduce the restriction whilst keeping the person safe. Some of these restrictions were very limiting such as wearing a clothes protector all day and wearing a body suit at night where some people were denied access to their own bodies. The managers and provider had not understood the potential impact and significance of these restrictions.

This service scored 25 (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 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 providers were not ensuring people had up to day accessible risk assessments and reviews. Managers had recently completed care plans for people but staff were not using these or being trained/supported to do so. Managers were not effectively assessing, exploring, and reviewing people's 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 being utilised and understood by staff.

People could not tell us about this.

Staff had shared concerns to the GP when people were unwell. But staff were not all knowledgeable about the risks people faced. Leaders 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 leaders.

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.

There were poor processes and no processes in place to share all relevant information with professionals and staff. Often staff were not enacting the advice for two people from Speech and Language Team (SALT) professionals. Correct information was not being shared with Deprivation of Liberty Safeguarding DoLS assessors. Therefore we could not be assured information would be shared appropriately if required to other services.

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 worked well. The provider was also not auditing people's care experience to consider this.

People could not tell us about this.

Staff could show us consent to care forms. One member of staff told us a key improvement since the last inspection was they now ask people what they wanted to wear each day. More complex forms of consent and restrictions on people's freedoms staff were unable to comment on.

The managers and leaders had completed best interest processes for people who experienced restrictions in their lives such as wearing a body suit. But they had not completed this process for all the restrictions people faced. Nor had they ensured these best interest processes were documented according to best practice. The provider was not advocating for people's rights by ensuring restrictions were being regularly reviewed and due consideration was given to lessen the restrictions where possible.