Last updated: 9 February 2026
"Team culture and planned activities offer some positives, but poor management oversight, night staffing shortages, and out-of-date training create serious risks."
A person had experienced degrading treatment. They had also been put at risk and experienced an injury.
The registered manager had not followed the provider's own policy when accessing CCTV footage remotely and did so in a way which made staff feel overly observed.
Staffing levels were not sufficient to support people at night who were awake or wanted to be awake.
Some training was out of date or not happening at all, this included first aid training, the manager and providers had not identified this issue until we had pointed it out to them.
The registered manager and provider had created a management model which did not ensure staff practice, risks, and people's daily life experience was being thoroughly checked and assessed.
Planned events were walks to the local park, bus rides sometimes to no destination or to go to Brent Cross, and swimming which was seasonal. But few other options were provided.
Management fails to properly oversee care, missing risks and quality issues that put everyone at risk.
There were key shortfalls with how the provider and the registered manager assessed the quality of the care provided at Two Rivers.
Not enough staff especially at night, so shifts are stretched and people go without support.
Staffing levels were not sufficient to support people at night who were awake or wanted to be awake.
Training is out of date or missing key areas like first aid, leaving staff unprepared for the job.
Some training was out of date or not happening at all, this included first aid training.
AI Generated
Last inspected: November 2023
Management Quality
Well-led: Inadequate
Direct feedback from current and former employees

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