Riverside House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe. There was an increased risk that people could be harmed.

The service was in breach of the legal regulations in relation to safe care and treatment and good governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

An effective system was not fully in place to ensure lessons were learned from accidents, incidents and safeguarding concerns. Falls analysis was not always accurate, and the computerised care planning system was not being used effectively to monitor risks and outcomes. The safeguarding log had not been fully completed to document outcomes and lessons learned. Staff supervision and appraisals had not been carried out as planned, limiting opportunities for reflection and improvement.

By the end of the assessment, the new manager showed us the systems she was implementing to strengthen oversight and ensure lessons were learned. Following our feedback, the provider and new manager formulated an action plan to make sure improvements were made promptly. Whilst we were satisfied that action was being taken, the new processes still needed to be fully embedded into practice to ensure consistency and sustainability.

An effective system was not fully in place to ensure safe processes supported people when moving into or through the service.

Preadmission and admission assessment processes were not consistently effective in confirming that the home could meet people’s needs. This increased the risk of people receiving care that did not fully meet their requirements.

During the assessment, the new manager told us she would strengthen these processes and said that she would carry out all preadmission assessments in person.

An effective safeguarding system was not fully in place. The local authority told us that safeguarding concerns had not always been reported in a timely manner and the correct referral process was not followed. The safeguarding log had not been fully completed to document outcomes and lessons learned.

By the end of the assessment, the new manager had organised safeguarding refresher training for staff and introduced a new safeguarding log to provide an overview of referrals and outcomes.

An effective system was not fully in place to ensure risks were assessed, monitored and managed. We identified shortfalls in the assessment of risk for falls management, medicines management, nutrition, and catheter care. For example, 1 person’s catheter was not secured correctly, and their catheter bag was not properly positioned below bladder level, which is important to help prevent backflow and reduce the risk of infection.Care documentation showed conflicting information about diet textures and choking risks, and risks associated with eating and drinking in the community were not documented.

By the end of the assessment, the new manager had begun addressing these issues. She showed us the actions being taken to strengthen risk management, including reviewing care plans, improving falls analysis, and ensuring staff understood best practice in relation to catheter care and risks relating to nutrition.

An effective system was not fully in place to ensure the environment and equipment were consistently safe. Full length windows upstairs had not been adequately assessed in relation to the risk of falls. Although window restrictors were in place and the provider told us that a glazing specialist had confirmed the presence of safety glass, the risk assessment did not cover all necessary areas to determine whether additional controls, such as a barrier were required. We also found a mattress displaying a red alarm indicator which staff had been unaware of. Fire drills had been carried out; however, simulated fire drills had not taken place, which meant staff had not practiced emergency procedures in a realistic scenario.

By the end of the assessment, the new manager had already begun addressing these issues. She showed us the actions being taken to review environmental safety, including making sure that staff understood equipment alerts, she had organised fire warden training to strengthen emergency preparedness and they were reviewing further window safety arrangements.
 

An effective system was not fully in place to ensure staff were supported and trained. Staff supervision and appraisals had not been carried out as planned, which meant staff did not always have structured opportunities to reflect on their practice, identify learning needs, or receive feedback to improve the quality and safety of care. We also identified gaps in staff knowledge relating to the electronic care planning system, falls management, nutrition, risks relating to 1 person’s fluids, catheter care, and medicines management.

People and relatives told us there had been frequent changes in staff, including managers. One person told us, “They do everything they can to make my care good, although recently a high turnover of staff has made that task more difficult.” People also told us that agency staff were used, particularly at night, and they were not always skilled or knowledgeable about people’s needs. A person said, “The day staff are really good but recently the night staff seem to be all agency...One came in with a commode and put it the middle of my room instead of next to my bed, I couldn’t reach it.”

We observed that staff deployment during mealtimes on the first floor did not consistently support positive engagement or ensure people received timely assistance. However, the mealtime experience in the main dining room on the ground floor was positive. Staff were present and interacted well with people.

The new manager introduced measures to improve the mealtime experience on the first floor, including pausing non essential duties during mealtimes so staff could focus on supporting people with eating and drinking. She also carried out unannounced night time visits to monitor staff practices and ensure care was delivered safely and appropriately.

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.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People and relatives told us the home was clean. One person said, “This place is spotless, cleanliness wise.”

The provider did not make sure that medicines arrangements were safe and met people’s needs, capacities and preferences.

Medicines were not always administered as prescribed. We found discrepancies in running balances and medicines administration records, including gaps, unclear non-administration codes, and incorrect doses. Handwritten entries were not consistently double-signed in line with best practice. Double-signing is required to verify accuracy, prevent transcription errors, and ensure clear accountability for medicine administration.

Guidance for ‘when required’ and topical medicines lacked detail to ensure consistency. Some medicines were out of stock and could not be administered as prescribed. Oromorph, an oral morphine solution used to treat moderate to severe pain, was not marked with the date opened therefore could be used beyond its safe three-month shelf life, increasing the risk of reduced effectiveness.

Following our feedback, the provider and new manager formulated an action plan to make sure improvements were made promptly.