Archived: Two Rivers Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People did not have accessible and complete risk assessments in place which identified and explored the risks which people faced. Managers had created care plans which were not in place before to support staff with how to manage the risks people faced. But staff had not seen these and they were not referring to them. There was no active plan from managers to support staff to use these plans. No work had been completed to ensure staff knew of and knew what to do about the associated risks of people taking some of their medicines. Poor risk assessing and planning continued with the management of people’s medicines. Staff did not adhere to safe practices when administering people their medicines. There was no regular auditing of medicines and management oversight for medicines was restricted to one member of staff. Staff supporting people at risk of choking did not all know what they must do when preparing these people their food and drinks to try and prevent them from choking. Staff were not referring to these people’s specialist food plans. Some staff did not know where these were located. There were infection control (IPC) shortfalls due to staff not following safe practices. For example, staff were wiping people’s faces with their clothes protectors which were wet from their excretion of excessive saliva. A process had been put in place staff were not to address soiled bedding but wait for the cleaning staff to address this when they attended later that morning. Aspects of the equipment and environment were damaged which meant these items could not be cleaned to a hygienic standard. We identified concerns about the storage of household cleaning materials and hand sanitisers alongside a considerable number of combustible materials in a vacant hot bedroom. The manager arranged for this room to be cleared quickly, but the managers and provider had not identified this safety issue.

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 were unable to tell us about this. They were unaware of the incidents and accidents which had happened over the last few months. Managers had reviewed incidents, but these were poorly evidenced.

When incidents took place effecting people's safety, staff were not being informed of these and what the lessons were. Managers were not ensuring the associated learning was being completed when incidents took place. No audit had taken place about whether lessons had been learnt and if new processes needed to created. The analysis of the incidents were sometimes incorrect and did not go far enough to address the issues.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People could not tell about this.

Staff could now tell us what potential abuse could look like and how they must report this to a manager. Staff were not sure how to contact the local authority if they had concerns. Managers also knew what abuse could look like. They had reported concerns to the local authority. However, sometimes there were time delays with this.

We saw a member of staff being neglectful towards a person. New staff were not being supported to complete their work in a safe way.

Incidents and accidents when neglect may have occurred were not documented accurately. Lessons from these were not being shared with staff. The provider was not assessing their safeguarding process to check it was effective. The provider was not always telling us when a safeguarding event took place.

People could not tell us about their experiences.

Staff told us they had not seen the new care plans and were not accessing the very lengthy historic risk assessments. Some staff did not know how to access these documents, including people's Speech and Language Teams care plans which explained how to prevent a person who was at risk of choking, from choking.

Staff were not using people's care plans to clarify what they needed to do and become knowledgeable about people's needs and the risks they faced. Managers were not actively promoting these plans and directing staff to them. One member of staff had not followed a person's plan who was at risk of choking and experiencing a low appetite.

There was no processes to involve people and their relatives in people's care planning and risk assessments.

People could not tell us about this.

Staff did not have an understanding about this. They had not raised environmental issues to the managers.

We found IPC (infection protection control) concerns due to damaged equipment such as bed bumpers, dented walls/woodwork which meant these areas could be not be cleaned effectively. Cleaning items, antibacterial wipes and combustible materials were inappropriately stored in a vacant bedroom. Soiled bedding was left until the cleaning staff arrived later in the morning, and the cleaning staff were not directed to this in order to prioritise it.

IPC best practice processes were not established in the service. This included when a person had an incontinence experience in the bed in the morning. Staff were told to leave this until the cleaners attended to it. This resulted in time delays in addressing this IPC risk. No environmental auditing was taking place to identify and address environmental issues. Many people's bedrooms and other parts of the home had decor which looked warn out and tired, there was no plan to address this.

People could not tell us about this.

Staff felt there was enough staff during the day and night to support people. Staff also felt they had enough training to promote people's safety. But staff who supported people who were at risk of choking were unable to tell us what they needed to do to do this.

New staff were not being adequately supported to care for people. Staff did not have an understanding about our expectations around people's lived experiences of having fun and enjoyment relevant to individuals, they were task focused. So staff could not meaningfully comment on whether there was enough staff to provide this aspect of people's care.

There were no effective processes to assess whether there was enough staff and if staff were suitably trained. Staff did not have an appropriate induction programme to ensure people were safe. There were multiple gaps in staff training which the managers and provider were unaware of and long periods when staff had not had supervisions. They did not have an effective process to ensure staff had completed the required training and were competent in their work.

People could not tell us about this.

Staff told us they had enough PPE personal protective equipment.

Staff were not adhering to safe IPC practices such as disposing of food debris and cleaning areas where people ate before the next person sat to eat there. They also wiped people's faces with soiled clothes protectors. We found a commode was not cleaned effectively.

The managers and provider did not have effective processes to ensure safe IPC practices were being followed by staff. There were no effective audits taking place in this area.

People could not tell us about this.

Staff did not know about medicine incidents when people did not get their medicines. Staff understood when they needed to administer people their medicines following a seizure. Staff did not always know how to follow safe medicine administration processes.

Medicines were not always stored safely. The medication cupboard was left open in between medicines rounds, and residents were entering and leaving the room. The key cabinet was also left open at all times. People were taking a medicine that had additional risks associated with these medicines but there was no information about the risks associated with these medicines. Staff were unaware of these associated risks. Managers had signed up to receive patient safety alerts however there was no log or audit trail of actions taken against alerts and no record of staff having read and acknowledged them. ‘Date opened’ stickers on liquid medicines often obstructed vital information on the original manufacture’s packaging or the pharmacy label. Temperature monitoring inside the medicines’ cabinet did not allow staff to identify fluctuations in temperatures, and there were gaps in temperature monitoring in the last few weeks for both room and fridge monitoring.