Riversdale Nursing 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 inspection we rated this key question good. 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. Regular checks relating to infection and prevention control were not always completed. We were not assured the provider was supporting people to minimise the spread of infection. The provider was in breach of legal regulations in relation to safe care and treatment. At the time of the inspection there were not enough domestic staff working at Riversdale Nursing Home and the provider had not implemented any temporary measures to address this.  The provider was in breach of legal regulations in relation to staffing.  

This service scored 47 (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 did not always ensure there was a proactive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. When incidents or accidents had occurred, these were recorded, however, staff had not always investigated or reviewed these to identify any learning that may be needed. Lessons were not always learnt to continually identify and embed good practice. However, leaders were able to give examples where some learning had been applied, such as actions taken in response to complaints. Some people and their relatives felt able to raise concerns and these would be acted upon, however, others did not feel able to raise their concerns about the service. One person said, “If I am honest, I don’t always feel comfortable to voice concerns.” 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. There was a pre-assessment process which ensured people’s needs could be addressed prior to their transition into the home. However, the provider did not always make sure there was continuity of care. Improvements were needed to ensure new information was used to develop care plans and risk assessments. We saw a care plan of a person with diabetes which was vague and the guidance for staff was unclear. Some care plans were inconsistent and not robust enough to enable unfamiliar staff to provide safe and effective care. For example, one person’s care plan stated they were at low risk of falls, however, other parts of the care plan stated they were at high risk of falls.  

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The providers system to monitor accidents or incidents was not sufficiently robust and did not include any action plans or lessons learnt. We found there had been an incident, where the provider had not sought required medical guidance quickly enough to ensure the safety and well-being of the person. We spoke to one person living at the service who we were concerned for regarding managing an infection. They told us, “They do a bit in the morning but then I try to sort it myself.” We raised our concerns with the registered manager, who acted on our concerns raised and sought medical support for the person. There were procedures in place to identify and raise safeguarding concerns so appropriate action could be taken. Staff told us they had received safeguarding training and were able to explain the process to us. Partners told us the provider followed local procedures for reporting safeguarding concerns and escalations.  

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. Leaders told us they formulated care plans for people, to ensure their consent was gained, for all aspects of their care plan. In some of the care plans and risk assessments we reviewed there was evidence of people being involved in the planning of their care and risk management; however, this was not always the case. Some of the care plans we viewed contained conflicting information. For example, one person’s care plan said they lack capacity to make decisions, but other parts said they were able to make their own decisions. We received some mixed feedback from people and relatives on how their risks were managed. One person said, “I feel safe here.” A relative told us “I feel completely assured [name] are safe." One person said, “Communication is poor, and we are not involved in care planning or managing risks.”  

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, and facilities supported the delivery of safe care. We observed some parts of the home were not well maintained, and areas of the home were unsafe. We found 4 radiator covers coming away from the walls. Loose wires in a person's bedroom caused a trip hazard. We found loose medication under someone’s bed. The providers health and safety audits had not identified these issues and risks. However, some people we spoke with including staff and relatives, told us there had been recent improvements to the environment. One relative said, “Despite the building being a bit tired the environment is very safe.” Another relative said, “Things have drastically improved.” When we asked a relative if they felt their loved one was supported to live in safe environment they answered, “For the most part I do. I do worry it may be cold for them.”  The home is currently undergoing renovation work, and we saw areas where improvements were being made.  

The provider did not always make sure there were enough staff available to maintain a safe environment. We observed support staff worked well together to provide care that met people’s needs. Most staff we spoke told us they did not have enough time to read people’s care plans. One staff member said, “I would like to have more time to read them, but I understand that it is busy. There were not enough domestic staff working at Riversdale Nursing Home and the provider had not implemented any measures to rectify this. The provider did routinely use agency care staff to fill gaps on the care staff rota. We discussed the importance of a robust induction for agency workers with the provider. The provider acknowledged out concerns, however, they were not able to assure us that agency staff who were working at Riversdale Nursing Home had received an induction. However, staff employed by the provider received effective support, supervision and development. They underwent pre-employment recruitment checks and received regular training such as safeguarding, manual handling and health and safety. We reviewed the training matrix, and this confirmed staff training was actively being kept up to date. 

The provider did not detect, assess or manage the risk of infection. We were not assured the provider was minimising the spread of infection or providing a clean, hygienic environment. The provider did not adhere to stringent infection control measures. Staff did not dispose of PPE correctly and left used PPE and soiled cleaning materials in people’s bedrooms. People's bedrooms, bathrooms and equipment were visibly dirty. Clinical waste bins were overly full. The providers infection prevention control (IPC) audits were not effective as they had not identified the concerns we found. The provider told us they only conducted these audits every three months. The registered manager told us they have group IPC training sessions with staff and people. All staff we spoke with confirmed they had received the required training and had enough PPE available. Most of the food we observed was in date and stored correctly. However, some of the storage areas were visibly dirty and some packets of food were not sealed appropriately.

The provider did not always make sure medicines and treatments were safe. Staff undertook regular audits of medication administration and medication stock checks. However, we found stock checks of medication were inaccurate. The processes in place to place to monitor medicines had not identified this and other concerns. During our checks on medicines, we found a controlled drug that was out of date. Body maps were not being routinely completed to guide staff for the application of prescribed creams. People were prescribed flammable emollients for skin conditions. These creams were stored in people's bedrooms. There were no risk assessments in place to ensure any potential risks were managed safely. The registered manager took action to ensure these concerns was addressed. We saw other people received medicines as prescribed and ‘as required’ protocols were in place.