Riverside Care Home

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 governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team accepted the findings from the inspection and worked proactively to implement timely improvements. They were keen to improve the service for the benefit of people and were open and honest through the assessment. The registered manager understood the duty of candour and the importance of acknowledging mistakes made.

The provider had a registered manager who understood the context in which they delivered care, treatment, and support, and who embodied the culture and values of their workforce and organisation. However, there have been recent changes in the leadership team, and the new team was in the process of developing the skills and knowledge needed to use the provider’s systems and processes. Staff reported they found the electronic care planning system difficult to use. This resulted in poor oversight of care records and delays in reviewing and updating support plans, which increased the risk of inaccurate or outdated information being used to guide care. In response, the provider arranged additional staff training on the electronic care planning system to improve compliance and ensure records were maintained accurately.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager told us they had an open-door policy to allow people, relatives, staff, and professionals to raise concerns or any feedback. Most staff we spoke with told us they felt comfortable approaching the provider and management team with issues and concerns about people’s care and had confidence these would be listened to and addressed. However, several staff said they felt the manager’s close relationship with some staff discouraged them from raising concerns with the manager.

The provider had a whistleblowing policy and complaints management system in place, and staff were informed of this as part of their induction.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders had a focus on diversity and inclusion. Leaders fostered a culture of acceptance and embracing different cultural beliefs with the staff team and people using the service. Protected characteristics were respected and plans put in place to ensure there was a zero tolerance to discrimination. Staff had received training and knew how to recognise discrimination within the workforce.

Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues and had put reasonable adjustments in place for some staff to help them carry out their role.

Managers engaged with staff via appropriate forums such as individual supervisions, various staff meeting types and staff surveys, to ensure their voices were heard.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance and accountability systems were not always robust and effective. The registered manager and staff had undertaken a range of audits prior to the inspection. However, these audits did not identify several significant issues found during the inspection, as detailed elsewhere in this report. The checks and audits failed to detect and address critical shortfalls, for example, risk management systems did not operate effectively.

Systems to assess, monitor and reduce risks to people’s health care and safety were not robust. People’s care plans were not always up to date, detailed and accurate therefore we could not be assured partnership working was always fully supporting effective care. Risks or hazards were not always identified and/or assessed. Where risks had been identified, risk assessments did not always contain clear guidance to ensure staff, including newly recruited and temporary staff, remained well-informed on the safest ways to support people.

The provider's electronic care planning system did not contain accurate or up-to-date information regarding individuals who were left and subsequently returned. The lack of appropriate guidance in people’s care records about their specific care needs and the high use of agency staff increased the risk of errors or omissions in people’s care.

Following the inspection, the provider took prompt action to address the concerns raised, adding these to an action plan. These actions significantly reduced the risks to people using the service. However, the provider’s governance and oversight mechanisms in place were found to be insufficiently robust.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The home had effective relationships with health and social care professionals and services. People were supported to attend appointments or were visited in the home appropriately to meet their physical or emotional health needs. The service had established good working partnerships links with the local GP surgery with face-to-face ward rounds. There were also regular visits to or from dentists, opticians, chiropodists, dieticians and others.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The management team acknowledged the shortfalls identified during the inspection and took immediate action to address concerns. The registered manager confirmed the implementation of a comprehensive service improvement plan following the inspection. This plan covered all areas identified during site visits and included actions already taken and those scheduled for implementation. The provider was open and transparent throughout the assessment process and demonstrated a willingness to make changes to improve the quality of care for people. The provider showed a willingness to embrace any changes that would improve the quality of care to people.