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Riverview Nursing Home Requires improvement

All reports

Inspection report

Date of Inspection: 8 May 2012
Date of Publication: 30 July 2012
Inspection Report published 30 July 2012 PDF | 49.89 KB

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 08/05/2012, looked at records of people who use services and talked to staff.

Our judgement

Peoples' needs were not assessed and care and treatment was not planned and delivered in line with individual care plans. Care and treatment was not planned and delivered in a way that ensured peoples' safety and welfare.

The registered care provider was not meeting this standard. We judged that this had a moderate impact on people who used the service and action was needed for this essential standard.

User experience

We used different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant that they were not able to tell us their experiences.

We observed people using the service whilst we looked around the whole home, we saw that most of them were in the lounges. People were clean and dressed appropriately.

In the lounge upstairs we saw that it was quiet and people were sat around the edge of the room, a television was on but no other activities were observed. We saw limited interaction from staff with these people using the service during our tour, although there were individuals' diet and fluid monitoring forms in the room and these had been completed.

The second larger lounge was downstairs and there were more things happening, we observed a carer playing dominoes with a person using the service and he told us "I enjoy dominoes as it is something I can still do." We also saw another member of staff playing ball with a number of people using the service. There was a television on in the corner and we saw drinks being served and people being supported with their drinks.

Another person told us "It's alright here."

Other evidence

Peoples' needs were not assessed and care and treatment was not planned and delivered in line with individual care plans.

When we arrived on site we were told the manager was on a training course, we asked to see the person in charge explaining we were inspectors from the Care Quality Commission. There was a nurse at the medicine trolley, we asked who was in charge and we were told that it must be the trainee manager. We asked the nurse who the nurse in charge was and they said there were two nurses on duty and when we asked which of them was in charge of the home they said it must be them. There was clearly no designated clinical leader at the time of our visit.

In order to follow up actions regarding records from the inspection in February 2012, we looked at the records of four people using the service, whom we had selected randomly from people we saw during our tour. These were found to lack coherence. For example, we saw that some of the assessments and care plans were blank and the daily records were not in the individuals' files. We asked the nurse in charge about daily records and they told us that the nurses kept their daily records in a separate file and there was a separate file where the care assistants kept their daily records. The daily records were not organised into individuals' records and we found blank sheets that had been poorly photocopied which meant that the continuation of the records was disjointed. The records were also kept in various places within the home which made it difficult to bring together all the records for an individual.

Having information about peoples' care and treatment in three separate folders, kept in three different places in the home and poorly recorded made it difficult to get a clear and accurate picture of an individuals' care and treatment needs and the actions being taken to meet those needs.

Care and treatment was not planned and delivered in a way that ensured peoples' safety and welfare.

Whilst looking at some of the rooms we noted a malodour in one room which the trainee manager could not account for. On closer inspection we found that the persons' duvet cover was damp with urine and yet the bed had been made up ready for the individual to sleep in. The provider promptly had this rectified but we have not been able to test that this compliance has been sustained.

In response to our findings, we looked at other care records of people using the service rather than the random sample we had intended to review. These records were found to be incomplete with daily records kept separately from the individuals care record and assessments. The records showed that some relevant assessments had not been completed and therefore, care plans had not been put in place.

We looked at incidents documented in the accident book and found a case where a person using the service had sustained an injury but medical support/advice had not been sought. The accident book stated that an individual had fallen resulting in massive bruising to their hip. The nurses daily notes documented the incident and indicated that the bruising should be observed however, there was no entry on the body chart which was found to be blank. We asked the nurse about this and they told us that the bruising had now gone.

We asked the nursing staff to explain another incident identified in the accident book, where we had found from their records that no action had been taken following a fall from bed. One of the nurses said they had made recommendations verbally to reduce the risk of harm to this person but these recommendations had not been recorded or acted on.