Riverside House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were being made to establish a clear shared vision and positive culture within the service. The home had experienced a period of significant change, which had affected consistency. Some staff told us that the culture had not always been positive.

The new manager told us she was actively leading and coaching the team to improve attitudes and embed positive practice. She stated, “I am leading and coaching the team,” and explained she was monitoring staff culture and behaviours to ensure improvements were sustained and aligned with organisational values.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively,

There had been several changes in management during 2025, which had led to instability within the service. These changes had created uncertainty for staff and people living in the home, affected morale, and contributed to inconsistency in oversight and decision-making. Differing management styles had also caused issues, as approaches to leadership and communication varied between managers.

By the end of the assessment, the new manager was actively working to stabilise leadership and strengthen team culture. A business services manager, who had started on secondment in September 2025, had also been appointed to a permanent post. In addition, the home was no longer being managed by a national care home management company, following the provider’s decision to move to a self-managed model to enable closer involvement in operations and drive improvements.

Staff did not always feel they could speak up and that their voice would be heard. One staff member told us, “I don’t feel that if I raise concerns to senior staff that they will be taken seriously.” Some staff told us they had raised concerns, but these were not acted upon. Supervisions had not been carried out as planned, limiting opportunities for staff to reflect on their practice, receive feedback, and raise issues in a safe and structured way.

By the end of the assessment, the new manager had begun addressing these issues. She told us she was introducing regular supervisions and appraisals to create structured opportunities for staff to raise concerns. She also implemented an open-door policy and encouraged staff to speak up, supported by safeguarding refresher training and clearer reporting systems.

Whilst the provider demonstrated they valued their workforce and promoted diversity and inclusion; feedback from staff about equality and inclusion was mixed, partly due to the impact of previous management changes and the culture they created.

The nominated individual told us that their priority was to invest in the staff through pay and training and in the property and equipment. They stated, “We will continue to do this with Riverside House and put the challenges of 2025 behind us.”

The new manager told us she was committed to creating a more inclusive and fair culture. Regular supervisions were being organised and carried out to provide structured opportunities for staff to raise concerns and discuss development needs.

An effective system was not fully in place to monitor the quality and safety of the home. We identified concerns about how governance systems monitored and improved care.

Risks relating to medicines management, nutrition and 1 person's fluids, catheter care, and falls management were not consistently addressed. Care plans and risk assessments were sometimes inaccurate or incomplete, and audits did not always identify or resolve these issues. The electronic care planning system was not always used effectively to monitor people’s care and support. For example, weight loss and falls risks were not consistently tracked because staff did not always record information accurately or had gaps in knowledge about how to use the system. This limited the provider’s ability to identify trends and take timely action to reduce risks.

At the start of our assessment, the home was managed by a national care home management company. The nominated individual told us they had identified an opportunity to move to a self-managed model to enable closer involvement in operations and drive improvements beyond what was possible with an external management company. They explained that this change aimed to strengthen governance, improve oversight, and ensure the home’s development aligned with their vision for high-quality, person-centred care. Following our second site visit, the national care home management company were no longer involved.

Following our feedback, the provider and new manager created an action plan to address the identified shortfalls and ensure timely action was taken to embed improvements and sustain positive change.

The home was part of the local community and people were supported to maintain social connections and participate in activities. People were supported to maintain their spiritual preferences, including visits from church representatives. There were visits from entertainers who created enjoyable experiences for people.

Systems to support continuous learning and improvement were not fully effective. 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, limiting the provider’s ability to identify trends and take timely action. Staff supervision and appraisals had not been carried out as planned, reducing opportunities for reflection, feedback, and professional development.

By the end of the assessment, the new manager showed us the new 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.