Riverside House

Updated 27 August 2025

The assessment took place between 30 October and 11 December 2025 and included visits to the home on 30 October, 12 November, and 26 November.

Riverside House is a care home providing accommodation and personal care for up to 46 older people, including those living with dementia. At the time of the assessment there were 37 people living at the home.

We identified that the home did not have the service user band for older people recorded in its details with the Care Quality Commission (CQC). Service user bands are categories used by CQC to describe the types of people a service supports. They help to ensure providers only deliver care to people they are approved for, based on their skills, resources, and environment. The new manager told us this would be addressed as part of an update to their Statement of Purpose and service user bands.

We carried out this inspection because concerns had been raised about the quality of people’s care, some of which were submitted anonymously. These concerns included issues relating to people’s safety and the management of the home.

During the assessment we identified shortfalls around people’s safety, the effectiveness of care, and the overall management of the home. We found the provider was in breach of the legal regulations relating to safe care and treatment and good governance.

The home had experienced a period of significant change during 2025, including several changes in management. These changes together with other challenges, had led to staff complaints, increased absences and departures. This had affected morale and stability within the home, resulting in inconsistency in care delivery and oversight.

Systems to keep people safe had not been fully effective. We found shortfalls with medicines management, nutrition, risks relating to 1 person’s fluids, falls management and catheter care.Governance systems had also been ineffective in monitoring quality and safety whichmeant risks were not consistently identified or addressed in a timely manner.

At the start of our assessment, the home was managed by a national care home management company. The nominated individual told us they had decided to move to a self-managed model to enable closer involvement in operations and drive improvements beyond what was possible under an external arrangement. By our second site visit, the management company was no longer involved.

On our third visit to the home, a new manager was in place who had been in post for a week. She had begun addressing the shortfalls identified both before and during our assessment. These actions were positive, but the new processes still needed to be fully embedded into day‑to‑day practice to ensure consistency and sustainability.

Despite the shortfalls, we identified areas of good practice. Safe recruitment practices were followed, reducing the risk of unsuitable staff being employed. Infection prevention and control arrangements were effective. Staff promoted people’s independence, choice and control in day to day decisions, and activities and support were adapted to meet people’s needs, which helped contribute to equitable experiences and outcomes. Further examples of how the home provided compassionate, person centred and responsive care are detailed within the people’s experience commentary below.

Updated 27 August 2025

Staff treated people with kindness. One person told us, “I came in on respite and loved it so much, I came in permanently. The care is excellent, including the cleaning and laundry staff. The staff talk to you in a civil manner, and they talk to me about my care. Just last night they came to talk to me about my oral hygiene and whether I could cope.”

People and relatives told us there had been changes in staff including managers which had affected the continuity of care. They said agency staff were used particularly at night and were not always skilled or knowledgeable about people’s needs. Despite these issues, people told us they felt safe. One person told us “The care is good and they certainly look after me. If I press the call bell, it seems they’re there before I know it. I definitely feel safe. There are a lot of changes in staff at the moment so much so, that I used to know their shifts but not now, however I do find them very friendly.”

Following our assessment, the provider wrote to us and told us, they always aimed to use the same agency staff for continuity, ensured all agency staff received an induction and had seen no evidence that agency use affected people’s safety. They also stated that agency use had been minimal in December.

We received mixed feedback from people on the quality of the meals. One person told us, “The menus are okay, but the quality varies from day to day. They do put on alternatives if I don’t like something.” The nominated individual told us they were reviewing the menu and explained that under the previous national care home management company, the home had been tied into a single food service provider. They said they wanted to source products locally to improve quality and choice, including using a local butcher, baker, and dairy. The butcher had already been introduced, and feedback on this change had been positive. The meals we observed looked appetising and we saw an emphasis on home baking. Fresh fruit and vegetables were also available.

We observed that the dining experience on the first floor did not always promote engagement. Staff were often busy supporting people to eat and drink in their rooms and administering medicines, which meant they did not have time to provide consistent support in the dining area. However, the mealtime experience in the main dining room on the ground floor was positive. Staff were present and interacted well with people. By our third visit, the new manager introduced a pause on non-essential duties during mealtimes so staff could focus on supporting people with eating and drinking to promote a positive dining experience.

The home was part of the local community and offered a varied activities programme to meet people’s social needs. People were supported to maintain community links through visits from church representatives, outings for shopping and leisure activities, and visits from entertainers who provided enjoyable experiences. A local hairdresser also visited routinely, enabling people to access personal care services without leaving the home.