Two Rivers

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider carried out comprehensive assessments of people’s health, care, wellbeing and communication needs. Care plans reflected people's assessed needs. Staff reviewed care plans regularly. Staff worked with people, their relatives and relevant professionals to assess and review needs and plan support. This helped ensure care reflected people's circumstances, preferences and changing needs. One relative told us, “They understand [person's] condition and give [them] care accordingly.”
 

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Managers ensured support plans reflected recognised good practice guidance, including information about texture-modified diets, dysphagia management, epilepsy and other health conditions. The training matrix showed staff had completed Autism Awareness training and received training in communication, person-centred care, Mental Capacity Act and Deprivation of Liberty Safeguards. Staff also completed Oliver McGowan training, which helps health and care staff understand how to support autistic people and people with a learning disability, and arranged refresher training where required.

Staff worked with external professionals, including speech and language therapists, psychologists and community learning disability teams, to understand how people communicated and expressed their needs. Staff used communication guidance and Positive Behaviour Support plans to recognise when people required additional support and respond in a consistent way that reflected their individual needs.

Staff knew people's healthcare needs and the support required to meet them safely. Staff monitored people's food and fluid intake, weight, continence and health conditions, which helped them identify and respond to changes in wellbeing. We observed staff supporting people in line with their assessed needs by offering encouragement and adapting their approach to the individual.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff involved GPs, district nurses, speech and language therapists, occupational therapists and psychologists when required. Staff incorporated their recommendations into care plans and risk assessments, to promote a consistent approach to care.

Staff described how they escalated concerns and got professional support when needed. Staff ensured information about people's health conditions, risks and support requirements was clearly documented and shared across teams to support continuity of care and ensure people received appropriate support.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to access healthcare services and maintain their health. Care records included health action plans, hospital passports, annual health checks and dental appointments. These helped staff and healthcare professionals understand people's health, communication and support needs and provide consistent care.

Staff monitored changes in people's health and wellbeing and sought professional advice when concerns were identified. For example, a GP reviewed a person's prescribed medicines following a change in their health needs, resulting in a change to their treatment. Staff also supported people to maintain healthy diets through nutritional monitoring, food and fluid charts, and by implementing professional guidance where required to meet individual nutritional needs.

Staff supported autistic people and people with a learning disability to access healthcare services through personalised support, communication guidance and reasonable adjustments that reflected their individual needs. Health action plans, annual health checks and ongoing monitoring helped staff identify and respond to changing health needs. Relatives confirmed staff arranged healthcare support when required.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff monitored people's health and support needs through reviews, daily records, food and fluid charts, weight monitoring and healthcare reviews. Staff reviewed people's goals, aspirations and support outcomes and updated care plans when needs or preferences changed.

Managers used audits to identify improvements and update care plans and risk assessments. This helped ensure people received care that reflected what was important to them and supported them to achieve positive outcomes.

Relatives told us people were safe, happy and well supported, and several described improvements in the quality of care since the current provider took over.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood the Mental Capacity Act 2005 and assessed people’s ability to make specific decisions about their care and support. When people could not make complex decisions themselves, staff worked with family members, advocates and relevant professionals to ensure decisions reflected people’s wishes and were made in their best interests. We reviewed Lasting Power of Attorney arrangements where these were in place.

Care records described how people expressed their wishes, including how they communicated without using words. Staff explained how they sought consent, recognised when people accepted or refused support, and adapted their approach accordingly. This helped people remain involved in decisions and exercise as much choice and control as possible.