Two Rivers

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood how to identify, report and respond to concerns. The registered manager reviewed incidents, identified learning and shared this with staff through team meetings and individual discussions. For example, following a recent fall, the registered manager shared lessons learned with staff and incorporated learning into care planning and risk management arrangements to reduce the risk of recurrence.

Relatives consistently told us they felt their family members were safe and well supported.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff worked with a range of healthcare professionals, including GPs, speech and language therapists, occupational therapists, psychologists, district nurses and community learning disability services, to help ensure people received coordinated care and support. Staff regularly reviewed care plans, risk assessments and healthcare information and updated these when people's needs changed. Staff used hospital passports to support people accessed other services, helping professionals understand people's needs and provide consistent care. Staff involved family members and relevant professionals in care reviews and significant decisions where appropriate.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood safeguarding responsibilities and explained how they identified, reported and escalated concerns. Managers strengthened safeguarding processes and oversight following the change of registered provider. Staff described an open culture where they could discuss and raise concerns without hesitation. Managers investigated safeguarding concerns, identified learning and used this to improve practice.

Staff promoted people's rights and used the least restrictive approach when supporting people. Managers applied for and monitored Deprivation of Liberty Safeguards authorisations where people required continuous supervision and restrictions to keep them safe. This helped ensure restrictions on people’s freedom received independent legal oversight and remained necessary and proportionate.

Relatives told us they felt their family members were safe and well supported. One relative told us, "[Person] is safe and I sometimes go unannounced."

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed individual risk assessments that considered people's health, mobility, signs of distress, communication and how they get out and about. Staff regularly reviewed risks and updated support arrangements. Care plans and risk assessments focused on supporting people to participate in meaningful activities, maintain relationships and access their local area safely. Staff understood people's individual risks and explained how they balanced safety with promoting choice, independence and community involvement.

Staff involved family members and relevant professionals in decisions about risk where appropriate. Staff promoted people's rights and used the least restrictive approach when supporting people. People joined activities, religious events and outings in line with their preferences, abilities and assessed support needs. One relative told us, “[Person] is safe. It’s a familiar comfortable environment for [person] and feels like home and the staff are attentive.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was clean, well maintained and presented to a high standard. Staff completed regular environmental checks to ensure safety. The provider ensured there were appropriate checks on fire extinguishers, fire safety systems and portable appliance testing. Staff completed regular fire drills and understood fire safety and emergency evacuation procedures.

People had personalised bedrooms and access to adapted communal and private areas that reflected their needs and preferences. Staff used specialist equipment, including hoists, slings and mobility aids, to support people safely. Managers completed personal emergency evacuation plans and environmental risk assessments. These arrangements helped ensure people lived in a safe environment that met their individual needs.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider deployed enough staff to meet people's needs. Staff and relatives told us staffing levels were sufficient to provide safe and responsive care. Staff consistently described a positive working environment characterised by strong teamwork and effective management support.

Managers provided regular supervision, competency assessments and training, including safeguarding, infection prevention and control, manual handling, epilepsy awareness and basic life support. Managers supported staff development through vocational qualifications and opportunities for promotion. There was a stable workforce, with several staff having worked at the service for many years.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean, odour free and hygienic. Staff completed infection prevention and control training and described good infection control practices, including appropriate hand hygiene and use of personal protective equipment. Staff labelled products with opening dates and conducted routine environmental and fridge temperature checks. Staff completed regular cleaning and infection prevention and control checks, including cleaning of high-touch surfaces, to help minimise the risk of infection transmission.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed clear systems for the safe management and administration of medicines, helping to ensure people received their medicines safely and as prescribed. Medicine administration records contained accurate information about people's medicines, allergies and administration requirements. Staff completed regular audits, and stock checks GPs reviewed medicines when people's needs changed, helping to ensure treatment remained appropriate and effective.