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Archived: Riverside Court Inadequate

Inspection Summary

Overall summary & rating


Updated 13 June 2018

The inspection of Riverside Court took place on 17 and 24 April 2018 and was unannounced on both days. At the last inspection in March 2017 the home was rated requires improvement and had six breaches of regulations in dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and staffing. Following the last inspection, we met with the provider and asked the provider to complete an action plan to show what they would do and by when to improve the five key questions to at least good.

Riverside Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Riverside Court accommodates 60 people across four separate units, each of which have separate adapted facilities. The home was divided into four units; Shannon unit was for people with nursing needs and living with dementia, Clyde unit was for people living with dementia and Trent and Avon units were for people who needed support with daily living activities, some of whom may be living with dementia.

There was no registered manager in post but a newly appointed manager had recently started at the home and was in the middle of their induction. They were in the process of being registered with the Care Quality Commission. 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.

We found serious concerns within the home. Staff were unaware of how to recognise or report safeguarding concerns and could not appreciate the support they were providing was, in some cases, increasing people’s distress and sense of anxiety.

Risks were identified but then not managed to reduce the likelihood of harm for people. Staffing levels were not sufficient to ensure people had a good quality of life as many remained in their rooms all day with little, or no, interaction. In addition, a lack of continuity of staffing meant people did not know who was supporting them each day and some agency staff displayed little knowledge of how to support people safely or effectively.

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; the policies and systems in the service did not support this practice. Although progress had been made in regards to obtaining legal authorisations to deprive people of their liberty, people were not encouraged to take positive risks and many had unnecessary restrictions placed on them.

Medicines were recorded, stored and administered safely for the most part apart from the use of PRN, or ‘as required’, medication. We found two people where medication had been used to reduce their behaviour which may be seen as challenging themselves or others rather than any evidence of positive behaviour management techniques. Staff appeared unaware of how to support people living with dementia effectively or safely, with minimum restrictions to their liberty.

Care records, although slightly more person-centred than found during the previous inspection, were large and often illegible, and staff readily admitted to not reading them as they did not have time to do so. Nutritional guidance was mixed and people did not have ready access to snacks and drinks throughout either day of the inspection.

We found the provider had not followed advice received from health professionals regarding suitable equipment to prevent pressure damage and other health-related issues. It was only on the second day of the inspection an order was put in for some equipment but this was not reflective of all p

Inspection areas



Updated 13 June 2018

The service was not safe.

There were insufficient staff to meet people�s needs safely, and risks were not always managed properly.

Medication was managed in accordance with requirements but there was inappropriate use of sedative medication for some people with more complex behaviour.

Some parts of the home were unclean as there was insufficient staff available to support this task.



Updated 13 June 2018

The service was not effective.

People were not supported with nutrition and hydration sufficiently and staff displayed a lack of knowledge about to support people living with dementia.

There was little evidence of best practice, and advice from other health and social care professionals was not always followed.

Staff did not fully understand the implications of the Mental Capacity Act 2005 or its associated Deprivation of Liberty Safeguards.



Updated 13 June 2018

The service was not caring.

Although some staff showed empathy, this was mostly lacking and some staff ignored people in distress.

There was no evidence of people�s involvement in their care planning.

People�s privacy and dignity were not respected.



Updated 13 June 2018

The service was not responsive.

Care records were comprehensive but not always reflective of people�s needs.

People did not have access to person-centred care as most stayed in their rooms, with little stimulation or attempt at engagement.

Complaints were acknowledged and investigated.



Updated 13 June 2018

The service was not well led.

There was no evidence of clear direction or leadership within the home. Although the manager was new, there were other senior leaders who had knowledge of the service but this was not shared with staff.

Governance was ad hoc and had not identified the concerns we found.

Partnership working was poor as advice was not followed and there was little evidence of staff learning from incidents.