Riseley House 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 inadequate. At this assessment the rating has changed to 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 that people could be harmed.

This service scored 56 (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 safety events. Lessons were learnt to continually identify and embed good practice. For example, analysis of falls data identified the fireplace in the lounge posed a trip hazard for people and contributed to some falls. Action was taken by the provider to improve the safety of the fireplace and reduce the risk of falls in this area of the home.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Some professionals provided examples where communication with staff could be better, although they acknowledged this was improving.

The provider did have clear processes in place to ensure when people were admitted to hospital, information was shared with other healthcare professionals, so they understood the person’s risks, needs and preferences. Staff members told us they were promptly informed of new admissions to the home, allowing adequate time to prepare.

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 with the local authority and other relevant organisations. Safeguarding logs were maintained, showing the actions taken. Relatives felt their family members were safe, with one commenting, “I can relax when I leave after visiting knowing that my loved one is safe and well looked after.” Staff had received appropriate safeguarding training and were able to recognise the signs of abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, we observed one person using a zimmer frame that did not belong to them. Additionally, some risk assessments contained conflicting information.

However, people and their relatives told us they felt safe when staff supported them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, we observed missing fire exit door signage, and rooms containing potential hazards to people, such as the sluice room and the hairdressing room, were unlocked. These issues were immediately rectified by the manager.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. For example, a review of staff recruitment files revealed gaps in employment history and medical declarations were not always explored. This was raised with the manager, who subsequently completed the relevant paperwork and reviewed all files. Staff had not received annual appraisals; however, these had been scheduled to take place with the manager in March 2025. However, staff reported they had received inductions and regular supervisions. One staff member told us, “I get supervision at least every 3 months, or sooner if needed.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, we identified 2 malodorous bedrooms and inappropriate storage of cleaning tools alongside wheelchairs. The manager rectified these issues whilst we were on site.

However, people and their relatives told us the home was always clean. One relative commented, “I have never known the home to not be clean and smell nice.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. For example, we identified that prescribed creams were stored in bedrooms of the wrong people. We informed the manager, who immediately removed the creams and implemented a daily check for staff during their walkarounds.

Relatives felt their family members were fully supported with their medication and were unaware of any medication errors.