5 October 2023
During a routine inspection
About the service
Five Rivers Living Residential Home is a residential care home providing personal care to up to 50 people. The service provides support to elderly people and people living with dementia and/or learning disabilities. At the time of our inspection there were 32 people using the service.
People’s experience of using this service and what we found
Right Support: People’s needs were not always assessed appropriately, and care plans did not always reflect people’s needs. People were not always supported by well trained staff.
The service felt clinical and lacked homeliness, as there was a lack of personalisation and decoration. People with specialist diets received food and drink appropriate for their needs. Records indicated health care professionals visited the service regularly.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right Care: People were not always protected from risk of falls. Staff did not have access to guidance on how to evacuate people safely in the event of an emergency. People did not always have access to a call bell to seek staff attention and were not always kept safe from the risk of developing pressure related injuries.
Infection prevention and control was sometimes lacking, and service cleanliness was poor. People were not always supported by enough staff and there was a reliance on agency staff to fulfil staffing requirements. Medicines were administered safely, and records were well maintained and up to date.
There was a lack of available guidance for staff in relation to end of life care, and people were not always treated with dignity and respect. We have made a recommendation the provider review staff training and monitoring in relation to providing dignified care.
Right Culture: Quality assurance systems and service oversight was not always effective. The provider was in breach of their regulatory conditions. The registered manager and provider were open and honest during our inspection and had knowledge of their legal responsibilities in relation to duty of candour.
People’s care plans did not always reflect care provided. Emotional support interventions were not always being recorded by staff. People’s communication needs were not always met effectively.
There was a lack of activities available for people, and there was a lack of meaningful engagement from staff. People were at risk of social isolation.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for the service under the previous provider was Inadequate (published on 7 March 2023).
Why we inspected
The inspection was prompted in part due to concerns received about medicines and quality of care. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. The provider took some action during the inspection to mitigate the most immediate risks.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Five Rivers Living Residential Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to personalised care, dignity, safe care and treatment, environment and equipment, governance and staffing, at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.