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, protect them from potential abuse 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, documents, people’s social experiences, staff's promotion of people's independence, 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 with the resources of managing the day to day needs of the care home and supported living services, and give them the time to make the improvements needed to address 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.

People could not tell us about this.

There was poor leadership at this supported living service. The provider did not have a shared person centred culture to assess, review, and monitor people's experiences of care. The provider had not created processes and checked these worked to ensure people had a person centred and quality care experiences in line with RSRCRC.

Staff spoke positively about the support they received from the managers.

The provider had not established an effective systems and structure to manage the supported living service. Both the residential and supported living services were managed by the one management team, also tasked to make the necessary improvements. There was no effective leadership for the day to day needs of the supported living services and the overall managers were too stretched.

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.

Staff were unable to tell us about known incidents when something had gone wrong and lessons needed to be learnt. Staff said they had training but we found gaps in the training provided.

The provider had not established processes and a culture of staff receiving regular training, accurate information, and opportunities to learn more about their expected roles and the requirements of their jobs. The provider had also not created a culture of managers and staff having high expectations for people to live their lives where they had opportunities to be as independent as possible and follow their interests and dreams.