Riverside Care Home

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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

The service was in breach of legal regulation in relation to ways people’s medicines were managed at the service.

This service scored 62 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported incidents appropriately. Learning from these events helped identify and embed good practice.

Following the last assessment, we saw clear improvements in care plans and in the delivery of safe and effective care, demonstrating that lessons had been learned. Staff continued to respond to safety concerns and carried out appropriate investigations and reporting. Learning from incidents was used to identify, share, and embed further good practice. These improvements now needed to be sustained and fully embedded to support ongoing progress.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, where safety was effectively managed and monitored. They ensured continuity of care, including when people moved between different services.

Processes were in place to support admissions into the service. Staff worked with health professionals from partner organisations who were based within the service to support this process. The provider followed appropriate procedures for managing new referrals, which included obtaining the person’s initial assessment and completing their own assessment of need before deciding whether they could meet the person’s care and support requirements. All new referrals were signed off by the registered manager to confirm the correct process had been followed and to support a smooth transition into the service.

People and their relatives told us they were involved in planning their care and support. One relative said, “I was involved in [loved one’s] care planning. I am happy with it and would say something if I wasn’t.” Another said, “I was involved at first and I have a copy of [loved one’s] care plan somewhere.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Relatives told us they felt their loved ones were safe living at Riverside Care Home. Comments included. “Absolutely safe they love my nana; [loved one] is well looked after” and “Yes, the staff are all lovely and they look after my [loved one] well”.

The provider had systems in place to safeguard people from the risk of abuse including the training of staff in how to recognise and report abuse. Staff understood their responsibilities to report concerns and told us they felt comfortable to whistle blow on poor practice.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Some people were subject to Deprivations of Liberty Safeguards, (DoLS). The provider had appropriate systems in place to ensure applications for DoLS were made in a timely way and any conditions imposed for DoLS agreements were kept under review.

The provider worked with people to understand and manage risks holistically. Staff delivered care that met people’s needs in a way that was safe, supportive, and enabled them to do the things that mattered to them.

The provider had made a number of improvements since the last assessment. Risk assessments and care plans contained clearer and more person‑specific information. Staff had access to improved guidance on pressure care, mobility, and risks associated with swallowing difficulties. The electronic care planning system had been updated to ensure prompts relating to the use of thickeners remained active when people returned from hospital, reducing the risk of unsuitable fluids being offered to people with dysphagia. Care plans for people at risk of choking included clearer instructions on how staff should respond if difficulties occurred during eating or drinking. The provider also introduced new risk assessments for people prescribed paraffin‑based creams and emollients to ensure fire‑related risks were more clearly identified and managed.

Environmental safety checks continued to be completed, and staff received regular fire safety training. Individual emergency evacuation plans were in place and had been reviewed. There had been significant improvements to the assessment and documentation of risks associated with people’s health, medical conditions, and care needs. Staff had clear guidance on how to minimise these risks and keep people safe. However, further work was required to ensure these improvements were fully embedded, sustained, and applied consistently across all areas of the service.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived and received care and support in a safe environment. Facilities were maintained appropriately and consistently supported staff to deliver safe and effective care. Staff carried out regular health and safety checks on the environment, including checks on maintenance issues, fire safety and equipment. The service arranged for assessments by external contractors in relation to gas safety, electrical installation and building fire risk assessment. Staff knew how to report maintenance issues which were monitored by the management team.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff responded to people's needs in a timely manner and care was delivered in line with people's care plans. Staff told us there was always staff on duty to support people safely. However, relatives gave us mixed feedback about staffing levels. Comments included, “I am happy, but the staffing ratio could be better” and “There never seems to be enough staff and they are always stuck in the eating area.” Another relative said, “There always seems to be plenty of staff around to me.”

There were processes in place for sharing information between staff. These included, a handover meeting, and daily flash meetings, to share information and improve practice.

Appropriate recruitment checks were conducted prior to staff starting work, to ensure they were suitable to work with vulnerable people. Records we looked at confirmed this.

Staff received a range of training to help ensure their knowledge was up to date. Staff were happy with the training they received. New staff completed an induction to ensure they understood what was expected of them. The induction process included shadowing more experienced staff. Staff felt well supported in their roles. Staff had regular supervision discussions with their line managers and received feedback about their performance.

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 were protected from the risk of infection as staff were following safe infection prevention and control practices. The home was clean, tidy and odour free. Toilets and bathrooms were equipped with appropriate hand hygiene facilities such as paper towels, liquid soap and foot operated pedal bins. Hand sanitiser was available in the home and posters were displayed about the environment to encourage compliance. Staff were trained in infection prevention and control, including hand hygiene. They used protective equipment, such as disposable gloves and aprons and confirmed these were always readily available.

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

The electronic medication administration record (EMAR) system was unreliable, with inaccurate stock levels and discontinued medicines still appearing as active. This resulted in people receiving medicines that had been stopped.

Medicines were not stored or organised safely. Trolleys contained unlabelled inhalers, mixed equipment and loose items, increasing the risk of error and contamination. Items marked as “found in the trolley” had been recorded as administered on the same day. Discontinued insulin remained available in the medication fridge.

Where people were prescribed medicines and creams to be taken or used ‘when required’ or with a choice of dose, the protocols to support their administration were still not detailed enough to ensure they could be administered safely. For example, one person did not have a care plan for their rescue medication. This meant staff did not have clear guidance about when to give the medication or what to do if the person became unwell. This created a risk of staff responding differently or in an unsafe way.

Controlled drugs were not reconciled in line with legal requirements, including stock belonging to a person who had died weeks earlier.

Thickening agents were accessible in communal areas and were not stored securely. This presents a significant safety risk because individuals could ingest the thickener directly, consume incorrect amounts, or use it without supervision.

Topical creams were stored in bedrooms without appropriate oversight.