Archived: Five Rivers Living

Updated 9 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors visited the service and 1 of these inspectors made calls to relatives and staff after the on-site inspection had concluded.

Service and service type

Five Rivers Living is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Five Rivers Living is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people who use the service and 4 relatives about the experiences of the care provided. We spoke with 11 members of staff, which included a nominated individual, registered manager, chef, housekeeper, laundry staff, care workers and senior care workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 8 care plans and multiple medicine records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including staff training records, policies and procedures were reviewed. After the inspection we continued to seek clarification from the registered manager to validate evidence found.

Updated 9 March 2023

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Five Rivers Living is a residential care home providing personal care to 23 people, at the time of the inspection. The service can support up to 50 people.

People’s experience of using this service and what we found

Right Support: People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Medicines were not always managed safety.

People were not always referred to relevant healthcare professional when needed and the provider failed to ensure advice and guidance from healthcare professionals was followed.

Right Care: People’s care was not always person-centred. A lack of care planning, registered manager awareness of people’s individual needs and staff training, meant care did not always promote people’s dignity, privacy and human rights.

There was no effective process in place to ensure people were protected from the risk of abuse, as staff were not always trained in safeguarding and did not all know the processes of escalating a concern if they had one.

Staff were not appropriately skilled to meet the needs of people and keep them safe.

People’s care, treatment and support plans had not reflected their range of needs and this therefore had not promoted their well-being and enjoyment of life.

Right Culture: People did not live inclusive and empowered lives. For example, where Deprivation of Liberty Safeguards (DoLS) conditions were in place, these were not always followed.

People were not supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people had not received compassionate and empowering care that was tailored to their needs.

People and those important to them, including advocates, were not involved in planning their care.

The provider had not enabled people and those important to them to work with staff to develop the service. There was a lack of structured feedback sought through questionnaires and meetings.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 May 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received concerns in relation to care plans and risk assessments not containing up to date information to guide staff how best to care for people and mental capacity act assessments not always being in place. Additionally, we carried out an inspection of this service on 5 April 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the dignity and respect, and consent practices at the service. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Requires Improvement to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Five Rivers Living on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to need for person-centred care, consent, dignity and respect, safe care and treatment, good governance and staffing at this inspection.

Our regulatory response has concluded and will be published 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this time-frame and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.