Five Rivers Living Residential Home

Updated 2 December 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.

Inspection team

The inspection was completed by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Five Rivers Living Residential Home 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 Residential Home 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 all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We visited the service on 2 separate days to complete the inspection. We checked the environment on each site visit. We spoke with 12 people living at the service and 4 relatives, to gain feedback on their experiences of using the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 10 staff including the area manager, registered manager, and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a selection of records for 14 people including care plans, risk assessments, capacity assessments, medicine records, daily notes, and other monitoring charts and records. We looked at 8 staff files in relation to recruitment and reviewed the providers training and supervision monitoring documents. A variety of records relating to the management of the service including, quality checks, policy and procedures, incident reporting and health and safety were examined.

Updated 2 December 2023

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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.