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 new care plans to support staff with how to manage the risks people could experience. 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 were aware of and knew what to do about the associated risks of people taking some of their medicines. There was no regular auditing of medicines and management oversight for medicines was restricted to one member of staff which posed a risk to people. People did not have up to date hospital care plans to promote their safety if they were admitted to hospital. A potential safeguarding event took place when a person could have come to harm, however staff did not raise this matter with a manager to investigate and alert the local authority, nor did the managers identify this matter through their daily checks.

This service scored 28 (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 be created. The analysis of the incidents were sometimes incorrect and did not go far enough to address the issues.

People could not tell us 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, we identified a person had been potentially harmed, staff had recorded the injuries on a record but not followed the process to report this to a manager.

The managers and provider had not tested the safeguarding processes to assure themselves the staff were knowledgeable of this. Nor were they completing regular checks about incidents and accidents to see if there was potential abuse or neglect taking place. 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 always telling us when a safeguarding event had taken place.

People could not tell us about this.

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 where to find these documents.

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

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

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. Nor was there tested and effective processes to pass information onto staff when incidents happened, and if people's needs had changed or they had been unwell.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People could not tell us about this.

Staff who supported people with their medicines said they felt confident and able to do this safely. Staff were not able to tell us about the associated risks of some medicines which people were taking.

Some people were taking medicines that required additional monitoring to ensure they were safe, but this was not happening. There was no information about the additional risks associated with these medicines such as care plans or risk assessments to support staff to be knowledgeable and respond to concerns if needed. Managers were also not aware of these risks. When GP reviews were required for certain medicines, managers could not evidence these reviews had happened. There was no log or audit trail of actions taken against medication safety alerts received and no record of staff having read and acknowledged these. Temperature monitoring inside the medicines cabinet and fridge did not allow staff to identify fluctuations in temperatures, and there were gaps in temperature monitoring.