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Inspection Summary

Overall summary & rating


Updated 18 January 2019

We undertook an unannounced focused inspection of River View Care Centre on 3 December 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our September and October 2018 comprehensive inspection had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This is because the service was not meeting eight legal requirements at their last inspection.

No additional risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity, so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

River View Care Centre is a care home with nursing, which provides services across three floors that are further split into seven units. The care home specialises in providing a service to older adults who may be frail due to age or disability as well as individuals living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service is currently registered to provide accommodation to a maximum of 137 residents. Following the last inspection rating of Inadequate, the service was placed in special measures. A restriction was placed on new admissions, which meant the service was unable to accept any new people to River View Care Centre. CQC imposed a further three conditions on the service. Two of these were met within the stipulated time frame. One condition remains outstanding, with the Commission accepting the reason presented for the delay. The restriction on admissions remains in place until agreed otherwise by CQC.

The service has a registered manager. A registered manager is a person who has registered with CQC 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.’

The service remained unsafe. People were not kept safe from the risk of harm. Documentation was poor and conflicting in information, and staff were unable to provide assurances as to their understanding of the individual risks associated with people's care and support needs.

People were not appropriately monitored for adequate food and fluid intake and weight checks. As a result, potentially people did not have referrals made to external professionals in a timely way. Where bedrails were required to keep people safe, these were not always used. Staff attended to people, but failed to recognise the risk the lack of bedrails presented.

Staff were unaware of people’s changing health needs. Documentation, although stated as reviewed and therefore up to date, was inaccurate and not reflective of people’s needs. This meant that people were potentially exposed to unsafe care and treatment.

Governance of the service remained inadequate. Current systems and processes used as part of the audit process by the service were not effective in monitoring, assessing and improving the quality of the service. Where audits had been carried out in relation to people's care plans and risk assessments, these had failed to identify inaccurate and misleading information.

Poor staff knowledge of people and safe practice, in addition to inaccurate documentation, raised concerns in relation to staff professionalism. These issues were discussed during the inspection with management.

The service remained in breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 20

Inspection areas



Updated 18 January 2019

The service remains Inadequate.


Requires improvement

Updated 30 November 2018

The service was not always effective.

Appropriate measures had not been implemented to ensure people's nutritional and hydration needs were met, due to poor recording and documentation.

The service failed to cross reference records and make referrals as required.

The service although catered for people with dementia, did not fully meet their needs. The environment was not appropriately designed to meet people’s needs.

Staff received supervisions and attended team meetings.

Consent was not always sought from people. Although staff had received training in the Mental Capacity Act.


Requires improvement

Updated 30 November 2018

The service was not always caring.

Privacy and dignity was not protected, with doors being left open when assisting with personal care, and where issues around self-preservation of dignity were known for people.

There was insufficient evidence to illustrate people were involved in their care development.

Whilst the service generally ensured people’s confidentiality was maintained when speaking about people to one another. Daily records were filed near each room entrance, therefore accessible to any visitors.



Updated 30 November 2018

The service was not always responsive.

People's care plans were not reflective of their changing needs.

People did not have all their personal care needs met.

Appropriate alternative measures had not been put into place to manage and respond to people’s needs as and when these arose.

Complaints were appropriately managed and recorded.



Updated 18 January 2019

The service remains Inadequate.