Archived: Riverview Residential Home

Updated 30 September 2020

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 7 April 2017, and was unannounced. The inspection team consisted of two inspectors.

Before the inspection, we reviewed the information we held about the service. This included notifications about events that had happened at the service, which the provider was required to send us by law. For example, serious injuries, safeguarding concerns and deaths that had occurred at the service. We also gained feedback about the service from local authority commissioners.

We spoke with three people who used the service, two staff and the deputy manager. We observed how staff supported people throughout the day and how staff interacted with people who used 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 viewed five records about people's care and four people's medicine records. We also viewed records that showed how the service was managed, which included quality assurance records, and staff recruitment and training records.

Updated 30 September 2020

We completed an unannounced inspection at Riverview Residential Home on 4 April 2017. At the last inspection on 25 August 2016, we found there was a breach in Regulation 17 and improvements were needed to the way the service was monitored and managed risk and governance. We received an action plan from the provider, which stated that the required improvements would be made by the 29 September 2016. At this inspection we found that the action plan had not been met and we identified further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Riverview Residential Home is registered to provide accommodation with personal care for up to eight people. People who use the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection the service supported seven people.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

The service did not require a registered manager because they are registered as an ‘individual’. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was managing the service, and there was also an assistant manager and a deputy manager.

Risks to people’s health and wellbeing were not consistently identified, managed or followed to keep people safe.

We found improvements were needed to ensure staff were deployed across the service effectively to ensure they were available to provide support when people needed it.

We found that medicines were not consistently managed in a safe way.

People were protected from the risks of abuse because swift action had not been taken by the provider to ensure people were protected from possible harm.

Staff told us they received training. However, we found that some of the training they had received was not effective. There were no systems in place to ensure that staff understood and were competent to support people safely and effectively.

People were not always supported in line with the requirements of the Mental Capacity Act 2005, because staff and management did not have a clear understanding of their responsibilities.

The provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not identified and rectified by the provider.

Systems in place to monitor accidents and incidents were not being followed or managed to reduce the risk of further occurrences.

Advice was not always sought from health professionals in a timely manner to ensure people’s health needs were met effectively.

Improvements were needed to ensure that people were able to access hobbies and interests that were important to them.

People’s care records did not contain an up to date and accurate record of people’s individual needs and reviews that had been undertaken were not effective in identifying changes to people’s care needs. This meant that people were at risk of receiving inconsistent care.

People were supported to eat and drink sufficient amount and staff understood people’s nutritional risks.

People knew how to complain about their care and the provider had a complaints policy available for people and their relatives.

People and staff told us that the registered manager was approachable and staff felt supported to carry out their role.

People told us they were treated in a caring way and staff promoted their dignity. People were supported to make choices about their day to day care.