Archived: Two Rivers Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider had failed to make any significant improvements since the last inspection. We still found a lack of effective risk assessments and care planning to promote people’s safety. When incidents and accidents took place, these were poorly documented, and the mistakes and lessons were not being shared with staff. Staff lacked the training and support to provide medicines safely, adhere to IPC practices, minimise the risk of people choking, and offer a person centred care experience. The provider despite having an action plan were not assessing the quality of the care provided. They were not conducting any assessment of people’s records and documents, the environment, people’s social experiences, whether the restrictions were lawful or necessary and whether staff had the skills and support to do their jobs well. There was still an institutionalised culture of blanket routines, meal options and opportunities for people. The provider had failed to make improvements into the culture of the staff team of seeing people as individuals. They had also failed to equip the managers the resources of managing the day to day needs of the care home and supported living sites and the time to make the improvements needed to address or start addressing the significant failures found at the last inspection.

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.

Staff and managers said they had people's best interests at the centre of the work they did. Although, staff and managers had good intentions they had not translated this into actions to improve people's experiences of care. People did receive healthcare support and input when this was needed. But staff and managers did not have the knowledge and understanding of when to seek professionals advice and what about in terms of people's rights and opportunities to live fuller lives.

The provider had created an action plan to respond to the closed cultural and failures identified at the last inspection. But this had not impacted on the culture and delivery of care at the service. Staff had low expectations for people beyond good healthcare and personal care needs. The provider had failed to create a shared culture in line with RS,RC,RC and create processes to assess these values were being put into practice.

Managers told us they did not have the time and resources to complete the improvement plan created by the provider and manage the day to day running of the home and three supported living sites. There was an open culture at the home amongst the managers with the CQC in relation to what they were doing and the challenges they faced.

The provider had not created effective management structures where managers could lead effectively. The provider was not auditing/assessing this aspect of the leadership team to assure themselves managers were doing this. The provider was not knowledgeable about what effective leadership looked like to fulfil our fundamental standards of care we expect providers/managers to provide. There was an open culture in the management team.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt supported and they believed the managers were supporting them to provide safe care to people. Staff were aware who to speak with to raise a concern. However, staff were not always being given accurate information about risk management and what people's needs were. When information had been produced it was either unclear, not concise, or staff were not being directed to it and encouraged to read and use the information.

The management structure was ineffective to respond to the day to day needs of the two services and make the necessary changes following the last inspection. There was limited and ineffective auditing taking place to assess the quality of the care and performance of staff. No audits and reviews were taking place about people's care experiences to enable the provider to assure themselves they were delivering good quality outcomes for people.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff said training had improved and they felt more knowledgeable about their roles. However, there were large gaps in training and supervision for staff.

The provider had not established effective systems to assess the quality of the service. They had not ensured managers had the resources they needed to enact the necessary changes. They were open to our assessment and feedback but unable to practically make the changes needed.