Riverside Court

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. We found the service was in breach of legal regulation in relation to the way people’s medicines were managed. However, staff clearly understood their safeguarding responsibilities. People told us they felt safe living at Riverside Court. Staff were recruited safely. The service proactively engaged with key external services to ensure people’s health and other needs were monitored. We received positive feedback from visiting professionals about Riverside Court.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most people told us they felt supported to raise any safety concerns. One person said, “I would speak to [relatives], but if [relatives] weren’t about then I would speak to [registered manager]. I think staff listen to me and do their best, yes.” Another told us, “I trust staff, so think they would listen and help if I had any worries.” However, not everyone was confident about to how to raise something they were worried about. One person told us, “I don’t know who I would speak to, to be honest. There are the odd one or two [staff] that would help.”

Staff feedback was mixed in respect of whether they believed accidents and incidents were investigated properly. Learning from incidents was not always clear. Not all staff felt wider learning and best practice was shared effectively following safety incidents. However, most staff confirmed they were listened to if they raised a safety concern. One staff member stated, “Yes. Without a shadow of a doubt.”

Processes were in place for staff to report accidents and safety events, and these were investigated where appropriate. The service appropriately reported safety events to external organisations. Key information following safety events was shared with staff at team meetings and on people’s Personalised Care System (PCS) record handover notes. People and staff were encouraged and supported to raise concerns during meetings, by submitting information in anonymous online feedback forms, or by approaching the registered manager at any time.

People had detailed ‘Hospital Passports’ in place containing important information about them which was passed to healthcare professionals when moving between services. People had regular access to a GP who they could speak to about their health or other issues concerning them. One person told us, “I saw the doctor yesterday actually. He comes regularly if you need to see him.”

Staff knew where information from visiting professionals should be logged in people’s care records. A senior carer would usually be responsible for accompanying healthcare professionals on site to ensure key information about people is captured and fed back to the registered manager where appropriate.

The service proactively engaged with key external services to ensure people’s health and other needs were monitored. Feedback from healthcare and other visiting professionals was positive about the service. It was acknowledged that the service had been responsive to any advice or concerns received, and that it had made and embedded positive improvements as a result. One partner commented they had “been impressed with the management particularly.” It was noted that the service’s move to digital care records had been beneficial to visiting healthcare professionals to allow for accessibility of information.

Processes were in place to ensure the service worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed or monitored. The service made sure there was continuity of care, including when people moved between different services. People's health conditions were documented, and people were supported to access a range of healthcare professionals.

People told us they felt safe living at Riverside Court. They also had confidence in the staff. One person told us, "I feel safe here. I am safe. I don't worry about anything. Staff are always kind. No-one has ever even said anything bad to me. I would let staff know if I didn’t feel well.” Another said, "Yes, I feel safe. I can speak to people here, so do feel safe. I have never had any situation where staff have been remotely unkind." Feedback from visiting healthcare professionals confirmed the service had effectively engaged in any safeguarding enquiries, leading to positive improvements being made for people.

Staff were aware of their safeguarding responsibilities. All staff were required to complete training relating to safeguarding and the protection of adults. Staff understood their role in keeping people safe from abuse, neglect, and other potential harm. Staff knew how to report and record safeguarding concerns, both internally and externally (if required).

We observed positive interactions with people by care staff as well as the wider staff team. Staff displayed warmth and empathy when supporting people and when trying to manage any risks to people.

Processes were in place to ensure the service worked with people and healthcare partners to understand what being safe meant to people and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety. The service shared concerns quickly and appropriately. Where people lacked capacity to make their own decisions, we found appropriate legal authorisations for Deprivation of Liberty Safeguards (DoLS) were in place.

The service had not always ensured it was secure to prevent people leaving when they required support to safely do so. However, people were encouraged to retain their independence. People were supported and encouraged to use equipment to aid their mobility. One person told us, "I can get about pretty well unaided. I have my stick to help me. Staff have told me to be careful and ask for help, but I am OK. I get to do what I want, which is staying in my room mostly. I do go downstairs sometimes, but have never been stopped from doing anything I want.” Another person said, "I am free to do what I want. I did go into town most days, so have the freedom to decide.”

Some staff expressed concern as to whether the service could safely meet the needs of some people given their individual needs and risks identified. We found some risk assessments for people were not always robust and sometimes lacked clear instructions for staff. This meant staff were not always able to provide care to safely meet people’s needs. However, most staff told us they had time to read people’s risk assessments to understand their support needs.

We observed staff providing care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. We observed that staff knew residents well, and staff responded positively when people communicated their needs. However, some staff appeared to lack confidence in how best to support individuals who were showing signs of distress.

Processes in place did not always ensure risks to people were robustly assessed with appropriate action taken to mitigate them. The service had begun improvements on adequately identifying the risks to the health and safety of people and ensuring they were doing all that was reasonably practicable to mitigate those risks. However, further work was needed to ensure risk assessments for all people using the service are comprehensive and sufficient. The registered manager responded well to our feedback and took on board our comments when reviewing their risk assessments.

People told us they felt safe and cared for in an environment which met their needs. One person said, "I can get about quite well still, so don't really need any help. I am capable of using the lift and can walk unaided. I stay in my room most of the time, but that is my choice. I do go down for lunch though, every day". Another person told us, "It is a lovely room. I am allowed to have it how I want. The staff come and clean it regularly and I have had my bathroom upgraded.”

Staff told us they had access to the equipment required to safely support people. However, some staff told us they had not participated in a fire drill. Not all staff were confident that people could be moved to safety in the event of a fire or other emergency. Following feedback, the service plans to introduce simulated fire drills to ensure all staff are aware of their responsibilities. This is intended to increase staff’s confidence in and ability to effectively move people to safety in the event emergency procedures are activated.

We observed the service to be clean, tidy and well maintained. People’s bedrooms were clean, with décor and furniture to a good standard. To ensure the safety of residents and oversight of visitors to the service, staff were required to assist all visitors to enter and exit the service. Visitors were required to ‘sign’ in and out using an electronic tablet to ensure the service can monitor who is on the premises at any time. However, we observed some risks in the environment (such as unlocked doors leading to potentially hazardous items) which had not been identified by the service. When we fed these back, the registered manager was responsive and quickly resolved them.

The service had conducted fire drills, but these were not comprehensive enough. Although health and safety checks were in place, the service did not always detect and control potential risks in the care environment. The registered manager was responsive to our feedback and amended internal documentation and audits to be more robust. The provider had invested in a programme of significant improvement works (which was nearing completion during our assessment period) which increased the safety and security of the service for people living there.

We received mixed feedback from people about staffing numbers. One person told us, “I don't need any more staff. I am happy with what I have got. They are lovely. I do have a call bell in my room, and they have come quickly when I have pressed it. I think that they are trained well, yes." Another person said, "I think it is about the right number of staff. I get on well with them and they have responded quickly when I have pressed for help. I don't know what training they get, but they seem OK." However, a person told us, "They probably need more [staff]. They can be a bit short on numbers sometimes. I do get along with them very well and I think they are trained enough.” They also said, “I did fall once. I pressed the call bell, and they came very quickly.” A relative told us, "There aren't enough staff here. I have seen people sat unattended while only two staff are putting people to bed. That isn't right."

Staff told us they didn’t think there were enough staff to ensure they delivered safe care, and to give people the time and support they often required. However, most staff told us they had enough training for their role, and they said there was enough time to complete the required training. One staff member told us, “We are constantly being trained, having supervisions and staff meetings to keep us up to date.”

We observed most staff to be deployed in the ground floor area of the service. This meant we observed people who needed or chose to remain in their bedrooms to have less regular interaction with staff. However, the service employed an Activities Co-ordinator who was observed spending meaningful time with people in a way which wasn’t task focused. The Activities Co-ordinator was also able to spend time with people preferring to remain in their bedrooms (as opposed to joining in group activities) and those people cared for in bed.

The service had appropriate checks in place to ensure staff were recruited safely. During the assessment, the service was in the process of recruiting new members of staff to the care team. The registered manager had oversight of staff training, and sourced additional training to increase the skills and knowledge of staff. There was a process in place to monitor and adjust staffing levels depending on people’s changing needs within the service. If agency staff were needed, the service endeavoured to use the same agency staff to maintain familiarity and continuity of care for people using the service.

People were clean and well-presented. People told us their home was kept clean and tidy. One person said, "It is always kept clean here.” Another person told us, "I think the home is clean enough, yes. There is always a cleaner about somewhere." The person added, "I wash myself, so I am happy with that. I could shower every day if I wanted to.”

Staff knew how and when to wear Personal Protective Equipment (PPE). All staff were required to complete training relating to infection prevention and control (IPC). Staff understood the importance of the service being kept clean. One staff member said, “We all have a responsibility to keep the home clean and tidy. If it’s a housekeeping issue then they are alerted and it is dealt with promptly.”

We observed that the service and equipment was clean and there were no malodours. PPE was available to staff at various locations around the service. We observed staff wearing PPE at appropriate times.

The service maintained a clean and appropriate environment to prevent and control infection. Clear and comprehensive cleaning schedules were in place. There were appropriate audits in place to ensure the safe management of equipment and minimise the risk of infection. The service detected and controlled the risk of any infection spreading, and shared concerns with appropriate agencies. The service had a Hand Hygiene Champion and a designated IPC Lead.

People did not always receive their medicines safely. Some Medication Administration Records (MARs) showed people had repeatedly missed medicines due to being asleep. Medicine for Parkinson’s disease was not routinely given on time or according to the service’s Medication Policy. Delays in administering these medicines can negatively affect people’s overall wellbeing and safety. People receiving their medicines ‘covertly’ (hidden in food or drink) had the correct documentation in place to allow this. However, advice from a pharmacist was not sought to ensure the medicines were given safely. People with prescribed medicines to be administered via a patch had limited documentation to show where previous applications had been on their body. This could lead to patches being applied in the same area continuously, which goes against the manufacturer’s instructions for safe use and efficacy. Our stock checks found some people’s ‘when required’ medicines were not immediately available if needed. Lack of access to ‘when required’ medicines risks people’s symptoms or conditions worsening. However, people were involved in decisions around their medicines, and the service supported people who were able to self-administer their medicines to do so safely.

Staff told us they didn’t like the electronic Medication Administration Records (eMAR) system in use at the service. Although it contained clear information as to when and why medication should be given, it often showed incorrect stock counts due to poor synchronisation. One staff member was unable locate retrospective entries we’d requested to review on the eMAR as they struggled to navigate the system. Some staff told us they lacked confidence in medicines administration. This indicated staff lacked sufficient medicines training and understanding of the eMAR system to confidently access important information and safely administer medicines to people. Prescription emollients were not always stored according to the service’s instructions to staff. This flammable product was observed to be stored in people’s en-suite bathrooms, subject to direct sunlight and other heat sources. Due to people’s bedroom doors often being open, emollients were often accessible to other people in the service and would be harmful if ingested by mistake. This indicated staff lacked sufficient knowledge as to the risks involved with this product.

Controlled drug stock checks were not routinely completed weekly in accordance with the service’s policy. There was a 3-week period when no stock levels checks were completed. Fridge and room temperature logs contained gaps, which meant the service could not always evidence medicines were being stored in the appropriate environment at the correct temperature. People prescribed ‘when required’ medicines did not always have in-depth protocols in place for these. The protocols we reviewed did not always match the current doses and formulations of the medicines prescribed and lacked clear instructions for staff. However, processes were in place to store medicines securely at the service. A locked medicines cupboard was in each resident’s room and secure trolleys were in the medicines room. Controlled drugs were locked in a separate cupboard. Documents confirmed two signatures when controlled drugs were administered.

Internal checks and audits had failed to identify the concerns we highlighted during the assessment. The registered manager took our feedback on board, reviewed people’s medicines needs against their routines, and adjusted medicine administration timings to better accommodate people’s usual sleep patterns. The registered manager also sought immediate advice from the service’s GP and liaised with the eMAR system supplier to put necessary improvements in place.