The Riverside Nursing Home

The Riverside Nursing Home is a care home providing personal and nursing care to up to 28 people. The service provides support to people aged 65 and over and to people living with dementia. At the time of our inspection there were 24 people using the service.

People’s experience of using this service and what we found

Medicine recording systems were not robust and the recording of prescribed creams was unclear.

Communal areas were not always supervised by staff. Some people and their relatives told us there was a lack of staff. We have made a recommendation about the provider reviewing their staffing levels across the service.

People and their relatives told us there was a lack of activities and stimulation for people accessing the service. We have made a recommendation about the provider reviewing their provisions to keep people accessing the service stimulated.

Auditing systems were not robust and governance systems required improvement.

Recruitment checks were robust to ensure staff were suitable to work with vulnerable adults. People were protected from the risks of abuse and staff were trusted to keep them safe. Staff had received training in safeguarding people.

People's care needs were risk assessed and care plans provided staff with the information they needed to manage the identified risk. Accidents and incidents were recorded and monitored. We were assured that the provider was preventing visitors from catching and spreading infections.

Staff had received an induction when they first started working at the service and training relevant to their roles had been provided. Staff had regular training and opportunities for supervision.

Good practice was observed during the lunchtime meal. People told us meals were of a very good standard and they enjoyed the food. 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.

The registered manager and staff worked with other agencies and professionals to ensure people received the appropriate care.

Person-centred care was promoted. The registered manager and staff demonstrated a commitment to people, and they displayed person-centred values. The service worked in partnership with other health and social care organisations to achieve better outcomes for people using the service.

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 this service was good (report published 28 August 2019).

Why we inspected

We received concerns in relation to the food provisions people received, the level of care and the provider’s recruitment processes. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We found no evidence during this inspection that people were at risk of harm from these concerns. However, we have found areas that needed improvement in relation to record keeping and auditing functions.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

Enforcement and Recommendations

We have identified a breach in relation to maintaining accurate records and operating robust auditing systems. We have made recommendations about the provider reviewing their provisions to keep people accessing the service stimulated and about the provider reviewing their staffing levels across the service.

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.

We found the following examples of good practice.

The provider was following best practice guidance in terms of ensuring visitors to the home did not spread COVID-19. Staff were adhering to personal protective equipment (PPE) guidance and practices.

Communal areas were well spaced and people, with support from staff were encouraged to maintain social distancing. Clear plans were in place for those who were required to self-isolate, and arrangements were in place for telephone or video contact with relatives. For those people who struggled with isolation additional support was provided.

The provider had created a safe visiting area within the home to allow people to see and speak to their friends and relatives. The room was well-ventilated and cleaned between visitors. For those who were nursed in their own rooms there were also clear visiting arrangements in place.

Staff continued to support people to access healthcare, and arrangements were in place should people need to attend hospital safely.

People’s experience of using this service and what we found

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.

People told us they felt safe and the system and staff training for the prevention of abuse helped protect people from harm.

There were sufficient numbers of well trained staff to meet people’s needs. Staff felt supported when they commenced employment at the service and could contribute to the running of the home at meetings.

The service was compliant with the Mental Capacity Act 2005 (MCA). Where required people had best interest meetings to decide upon the least restrictive practices to ensure their rights were protected.

People received a nutritious diet and had a choice of meals at each serving.

People said staff were caring and we observed there was good interaction between staff, people who used the service and family members.

People’s equality and diversity was respected and people could follow their chosen religion if they wished.

Plans of care were individual person centred and updated when there were any changes to people’s needs.

People were able to raise concerns if they wished.

The auditing of the facilities and services provided helped maintain or improve standards at the home.

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 this service was requires improvement (published 26 July 2018) and there were multiple breaches of regulation. Regulation 10 for insufficient suitable activities, Regulation 11 for not working within the principles of the Mental Capacity Act (2005) and Regulation 12 for unsafe equipment and not safely assessing people who were at risk of choking or pressure sores. The provider sent us an action plan detailing how they would address the breaches. We saw at this inspection that the necessary improvements had been made and the provider was no longer in breach of regulations.

Why we inspected.

This was a planned inspection based on the previous rating.

Follow up.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Riverside Nursing Home is a detached two-storey converted and extended building situated in the centre of the village of Littleborough, close to shops, local amenities and public transport. It has a car park to the front of the home which can accommodate up to eight cars. At the back of the home there is a small enclosed patio area.

The Riverside Nursing Home is registered to care for up to 25 older people, caring mainly for people living with dementia. There were 18 people using the service at the time of the inspection.

We last inspected The Riverside Nursing Home on 16 and 17 August 2017. During that inspection we found there were six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; unsafe and unclean premises, the privacy and dignity of people who used the service was compromised, suitable and sufficient activities and community involvement were not provided and there was no staff training in caring for people living with dementia.

Following the last inspection of 16 and 17 August 2017 we asked the provider to take action to make improvements. The provider sent us an action plan informing us that they had taken action to ensure the regulations had been met.

Following the last inspection of 16 and 17 August 2017 we also took enforcement action in respect of the provider failing to comply with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 20014 (an ineffective system in place to assess, monitor and improve the quality and safety of the service and records necessary for the management of the home were either not in place or were not accurate). A Warning Notice was served on the registered provider requiring them to comply with the relevant regulations within 14 days from the date of the Warning Notice. During this inspection we found that the provider had complied with the requirements of the Warning Notice.

The service was also placed into Special Measures following the last inspection which meant it was kept under regular review and inspected within six months of the last inspection report being published. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

During this inspection we found there had been a significant improvement and the provider had met some of the previously breached regulations. Due to the improvements seen on this inspection the provider has been taken out of Special Measures.

Although we found that improvements had been made we found further breaches of the Health and Social Care Act 2008 (Regulated-Activities) Regulations 2014. We found there had been a significant improvement in the safety and cleanliness of the environment. Fire exits remained free of obstruction, restrictors had been fitted to most of the windows, most wardrobes were now secured to the wall, the patio areas were litter free and a lock had been fitted to the laundry door. We also saw that most, but not all, of the broken furniture had been repaired or removed. We found however that some safety issues still needed to be addressed, such as; not all wardrobes were secured to the wall, there remained one unguarded radiator and one window remained without a restrictor.

We also found the following; the provider was not compliant with the legal requirements of the Mental Capacity Act 2005 (MCA), there was no risk assessment in place for a person at risk of choking, no pressure ulcer prevention plan for a person at risk of developing pressure ulcers and a lack of suitable and sufficient activities for people, particularly for people living with dementia.

The home did not have a registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home had appointed a manager who had been in post for approximately four months. We are aware that the manager had submitted their application to the CQC to become the registered manager.

Where regulations have been breached information regarding these breaches is at the back of this report.

To improve the care and support for people living with dementia we have recommended that the provider seeks out links with specialist dementia services who can give practical guidance and advice. This was because the environment, equipment and activities provided for people living with dementia were not adequate.

Although staff had received training in caring for people living with dementia their understanding of the types of dementia and how best to care for people living with dementia was limited. We have recommended that more in depth training be provided.

We have recommended that further improvements need to be made to the auditing of the service to ensure that a more effective quality assurance system is in place.

We received mixed comments about the staffing levels within the home although we found that people were adequately supervised and care was provided in a calm and unhurried way. We have recommended that the staffing levels are kept under constant review.

We found that staff did not always consider the need to preserve people’s dignity. One person had been left in an undignified situation in relation to their sleeping arrangements and some bedroom doors remained without locks.

People told us they enjoyed their meals and we saw that they were provided with a choice of suitable and nutritious food and drink to ensure their health care needs were met. We found however that there was no encouragement to promote meal times as a pleasant, social occasion. There were no menus for people to look at and the tables had no place settings or tablecloths. We have recommended that the meal time experience be improved and have also recommended that snacks, fruit and ‘finger food’ be left out for people to eat and enjoy when they wish.

People told us they received the care they needed when they needed it and were free to make everyday choices. They told us they considered staff were kind, had a caring attitude and felt they had the right skills and knowledge to care for them safely and properly. We found people were cared for by staff who were safely recruited and regularly supervised.

Suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred.

The medication system was safe and we saw how the staff worked in cooperation with other healthcare professionals to ensure that people received appropriate care and treatment.

Specialised training was provided to help ensure that staff were able to care for people who were very ill and needed 'end of life' care.

All areas of the home were clean and procedures were in place to prevent and control the spread of infection. Records showed that equipment and services within the home had been serviced and maintained in accordance with the manufacturers' instructions.

Procedures were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity or gas supply.

Records we looked at showed there was a system in place for recording complaints and any action taken to remedy the concerns raised. Records showed that any accidents and incidents that occurred were recorded and monitored.

The Riverside Nursing Home is registered to care for up to 25 older people, specialising in care for people living with dementia. There were 22 people using the service at the time of the inspection.

The home had a manager registered with the Care Quality Commission (CQC) who was present on the day of the inspection. 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 last inspected The Riverside Nursing Home on 01 December 2016 when we found there were four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in relation to an unsatisfactory recruitment system, a lack of staff training, support and supervision, no systems in place to monitor the quality of the service provided and a failure to send the required notifications to the Commission. Following the inspection the provider sent us an action plan informing us of what action they had taken to put things right.

During this inspection we found the provider was meeting the requirements of two of the four previous breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found however there was a continued breach of Regulation 17 (1) (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of the lack of an adequate quality assurance system. There were no systems in place to obtain feedback from people about the facilities and services provided.

There was also a continued breach of Regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found that the most of the necessary training had been provided however the majority of staff had not received training in dementia care to ensure that the needs of people living with dementia were met.

We also identified further breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. Where regulations have been breached information regarding these breaches is at the back of this report. Where we have identified a breach of regulation which is more serious we will make sure action is taken. We will report on this when it is complete. Where providers are not meeting the fundamental standards we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service.

When we propose to take enforcement action our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

The breaches were in relation to the safety of the premises, inadequate infection control procedures, failing to protect the privacy and dignity of people who used the service, the lack of suitable activities for people and failing to have records that are accurate and necessary for the management of the home.

The provider had failed to ensure the premises were kept safe, especially in relation to fire safety. Due to the issues of concern identified in relation to fire safety the Greater Manchester Fire and Rescue Service were asked to visit the home. Following the visit by the Greater Manchester Fire and Rescue Service we were informed that the service had been required to attend to some fire doors that were not closing fully and that advice was given in respect of keeping the means of escape clear. The fire officer informed us that the fire risk assessment was not available.

There were unguarded hot radiators and hot water pipes and some windows were without restrictors. This posed a serious risk of harm to people who used the service.

Although monthly infection control audits had been undertaken they failed to identify that clinical waste was not disposed of safely and that the patio areas of the home were dirty.

The privacy and dignity of people who used the service was compromised. This was because people were left in undignified situations, personal care was not effectively delivered, there was a lack of consideration for the environment that people lived in and there were no locks on bedroom doors.

We found that not all records necessary for the management of the home were completed accurately or were in place.

We found there was little to support people who used the service, especially those people living with dementia. There were no established links with community organisations to either support alternative social networks or provide opportunities for a range of different activities for the people who used the service.

There was inadequate signage throughout the home and people were not able to freely access outside areas. Having adequate signage helps to promote people's well-being; enabling them to retain their independence and reduce any feelings of confusion and anxiety.

People were provided with sufficient food and drink to ensure their health care needs were met; however there was no encouragement to promote meal times as a pleasant, social occasion. There were no menus for people to look at. The tables had no place settings, no condiments and tablecloths were creased. The majority of people stayed in their lounge chairs to eat their meals.

We received mixed views in relation to the staffing levels within the home. Overall we found there were enough staff on duty to meet people’s needs. We have recommended that a formal process is implemented so that the staffing levels are based on an accurate and current assessment of people’s needs.

We have recommended that the induction programme be improved to help ensure staff are prepared for their role by assisting them to develop their knowledge, skills and understanding.

We found that suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred.

The medication system was safe and we saw how the staff worked in cooperation with other healthcare professionals to ensure that people received appropriate care and treatment.

Procedures were in place to deal with any emergency that could affect the provision of care, such as flooding, a failure of the electricity and water supply.

Specialised training was provided to help ensure that staff were able to care for people who were very ill and needed ‘end of life’ care.

People's care records contained enough information to guide staff on the care and support required. The records showed that risks to people's health and well-being had been identified and plans were in place to help reduce or eliminate the risk.

Staff were able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

Records we looked at showed there was a system in place for recording complaints and any action taken to remedy the concerns raised. Records showed that any accidents and incidents that occurred were recorded.

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

The service had a registered manager. 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. However the registered manager had notified CQC that they were leaving the service on the 30 November 2016. The registered manager was present on the first day of our inspection. The business manager told us that they had recruited a new manager who would, once in post, apply for registration with CQC. They told us that until the person came into post the business manager would be temporarily managing the service.

This was an unannounced inspection which took place on the 30 November and 1 December 2016. The inspection was undertaken by two adult social care inspectors, an inspection manager and an expert by experience.

During this inspection, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of Care Quality Commission (Registration) Regulations 2009. This was because there were not robust recruitment procedures in place, staff did not received all the training they needed to carry out their roles effectively, systems to monitor the quality of the service were not robust enough and the service had failed to make the required notifications to CQC.

You can see what action we have told the provider to take at the back of the full version of the report.

The safety of people who used the service was placed at risk as the recruitment system was not robust enough to protect them from being cared for by unsuitable staff. Records were not available to show that the required checks had been made before ataff started to work at the servcie.Two staff files did not contain references and one other staff file did not detail a full employment history, including a written explanation for any employment gaps.

Staff felt supported and received an induction to the service, but did not receive all the training they needed to carry out their roles effectively. Staff we spoke with and the records available showed that not all staff had received all mandatory training. Most staff had not completed training in; first aid training, manual handling, MCA and DoLS, challenging behaviour, health and safety, nutrition and dementia awareness.

Systems were in place to monitor the quality of the service, but they were not robust enough and had not highlighted incomplete records and issues with cleanliness in some areas of the building.

The service had not notified CQC of all events they are required to. They had notified CQC of safeguarding concerns, serious incidents and events but had not notified CQC when DoLS authorisations were authorised.

We received mix views on staffing levels at the home. During our inspection there were sufficient staff present to meet people’s needs. We have made a recommendation that the service explores a formal process for assessing staffing levels.

There was a limited programme of activities and social events on offer to reduce people’s social isolation. We have made a recommendation that the provider considers current good practice guidance on suitable activities for people living with dementia.

On the first day of our inspection some people appeared unkempt. People we spoke with told us the staff were caring and knew them well. We observed staff offering support and found staff interaction with people to be caring, responsive and respectful. All the staff we spoke with were able to tell us about the people who used the service. They knew their likes, dislikes, support needs and things that were important to them. Staff spoke fondly about people who used the service.

Staff had received training in safeguarding adults. They were aware of the correct action to take if they witnessed or suspected any abuse. Staff were aware of the whistleblowing (reporting poor practice) policy in place in the service. They told us they were certain any concerns they raised would be taken seriously by senior staff in the service.

Medicines were stored safely and securely and procedures were in place to ensure people received medicines as prescribed. People had their health needs met and had access to a range of health care professionals. People at risk of poor nutrition and hydration had their needs regularly assessed and monitored.

People’s support needs were assessed before they moved into The Riverside Nursing Home. Care records contained information about people’s support needs, preferences and routines. Risk assessments were in place for people who used the service and staff. Care records we looked at had been reviewed regularly and had been updated when people’s support needs had changed. People and where appropriate their relatives had been involved in planning and reviewing the care provided.

We found the bedrooms we looked at and the communal areas were free from malodour, clean, had been painted and non slip flooring had been laid. We found there were few pictures or soft furnishing around the home. The business manager told us they planned to purchase additional pictures and photographs. We found some other areas of the home were not clean and some areas of the home were in need of repair or redecoration. The provider told us that there plans for refurbishing the building had been disrupted following major flood damage in December 2016. This resulted in the building being evacuated for a number of weeks and the purchase of new boiler's and laundry equipment and moving of the laundry. They told us all planned updating work for the building would be completed by the end of 2017.

The registered manager was meeting their responsibility under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people's rights were considered and protected.

Accidents and incidents were appropriately recorded. Health and safety checks had been carried out and equipment was maintained and serviced appropriately.

Policies and procedures we reviewed included protecting people’s confidential information and showed the service placed importance on ensuring people’s rights, privacy and dignity were respected.

There was a system in place to record complaints and the service’s responses to them.

It is a requirement that CQC inspection ratings are displayed. The provider had displayed the CQC rating and report from the last inspection in the entrance hall.