The Care Quality Commission (CQC) has dropped the rating for Two Rivers Care Home from good to inadequate following an inspection in August and September.
Run by Suncare Recovery Limited, Two Rivers Care Home is registered both as a residential care home and domiciliary care service. It provides personal care for up to eight people in the residential home, as well as domiciliary care for 15 people living in shared houses. The service is specifically designed to support autistic Asian women, and Asian women with a learning disability.
This inspection was prompted in part by an incident in which a person in the service was seriously injured. CQC are currently investigating this issue to decide whether further regulatory action needs to be taken and will report on this when able to do so. The information shared with CQC about the incident indicated potential concerns about risk management and dignified care, which were examined during this inspection and the findings are in this report.
As well as dropping from good to inadequate overall, the service has also dropped from good to inadequate for being safe, effective, caring, and responsive. It has dropped from requires improvement to inadequate for being well-led.
The service has now been placed in special measures, which means it will be re-inspected to ensure improvements are being made and kept under close review by CQC during this time to keep people safe.
Rebecca Bauers, CQC’s director for people with a learning disability and autistic people, said:
“When we inspected Two Rivers Care Home we were very disappointed to find leaders had allowed a culture to develop which was centred on routines and convenience instead of the people living in the service. Leaders hadn't established a culture of learning so staff weren’t supported to continuously improve the service.
“We saw that blanket routines were in place for mealtimes, meaningful activities and bedtimes. This meant people were experiencing restrictions in their day to day lives, which is unacceptable. Staff didn’t support people to share their personal goals, interests, or preferences in their care, and the service didn’t take action to meet these needs.
“People’s risk assessments were often generic and lacked detail, meaning staff didn’t always know how to meet people’s needs safely. Additionally, we found leaders who appeared to have a limited understanding of what restrictive practice looked like which meant people weren’t able to fulfil their best lives. This could infringe on their human rights.
“People’s privacy wasn’t always respected. The service operated a blanket approach to CCTV, with cameras across the home that were running 24 hours a day, including in bedrooms and when staff were supporting people with personal care. They hadn’t used a person-centred approach by adjusting this for people who didn’t need this much monitoring. People have the right to expect privacy in this place they call home, leaders must address this immediately.
“We’ve shared our concerns with the provider, who’ve taken action quickly to begin addressing these. We’ll be monitoring the service closely, including through future inspections, to make sure these improvements are carried out and that people are safe whilst this is happening. If we’re not assured people are receiving safe, person-centred care, we won’t hesitate to take further action. We stand by our public commitment to ensuring that reducing restrictive practices, and promoting positive cultures, are everyone’s business.”
Inspectors also found:
- Staff didn’t always treat people in caring and dignified ways, because leaders hadn’t provided the necessary training to support this. For example, inspectors saw staff announce people’s toilet breaks in front of other people
- Leaders hadn’t ensured serious incidents were reported to CQC in a timely way, even though this is required by law and CQC warned the provider about this at previous inspections
- Leaders hadn’t ensured staff had all the training they needed to provide safe care, including in areas such as first aid
- The use of 24/7 CCTV observation in the home also made staff feel overly watched, discouraging them from raising concerns.
However:
- People’s relatives said they felt confident that they could raise issues with leaders, and inspectors saw leaders had responded well to these concerns in the past
- The service supported people’s cultural and religious needs well.