Riversdale Nursing 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 inspection we rated this key question good. At this assessment the rating changed to requires improvement. This meant the management and leadership was inconsistent. Leaders did not always support the delivery of high-quality care. The provider did not have systems and processes such as effective regular audits of the service provided, and did not always assess monitor and improve the quality and safety of the service. The provider was in breach of legal regulation in relation Good Governance.

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 culture of staff and the feedback we received from people assured us the culture of the home was positive. The registered manager told us about the importance of creating a culture of fairness, respect and kindness. The registered manager gave us examples  where staff had raised  concerns and how this was taken on board and acted upon, with new procedures implemented. Leaders told us how it was important to share and learn from concerns and challenges identified. Some staff told us they felt able to voice their ideas and were confident they would be acted upon, however, others said they sometimes felt unable to suggest ideas. All the staff we spoke with told us information was shared with them through staff meetings and handovers.  

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Care staff were aware of their roles and responsibilities and when they needed to escalate concerns to senior staff. Most people and their relatives were happy with how the home was managed. One person we spoke with said, “The staff are wonderful.” Another person said, “I would give it 10 out of 10.” A relative said, “I can speak to all of the staff regularly.”   Feedback from staff was mixed. In the main staff told us they felt encouraged and supported by the management team. One staff member said, “When we have staff meetings, we are always encouraged to give our ideas.” Another staff member told us, “They make the effort to try to change things.” However, one staff member told us they were not confident that they would be listened to if they raised a concern. Another staff member said, “I sometimes worry about bringing issues up.”

The provider had policies and procedures in place to protect people and colleagues from abuse and harassment. Some members of staff told us they could always voice their concerns to the management team; however, one member of staff told us they did not always feel comfortable to raise a concern. Some relatives told us they felt they were always heard, and their views were considered. However, when we asked one relative if the felt confident that if they complain, they would be taken seriously and be treated compassionately, they answered “sadly no I don’t.” Due to this mixed feedback, we were not fully assured people would always speak up and raise concerns. The provider had a whistleblowing policy in place and staff were aware of this, along with the procedures they needed to follow. Leaders told us they had created an open-door policy to support staff to feel confident to speak up and share their concerns. We saw evidence of when concerns or complaints had been raised to the registered manager, they had taken action to address these.  

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. Staff told us they felt they were treated fairly. Leaders told us their staff were very important to them. There were procedures in place to consider staffs’ individual needs, this included considering staff’s diverse needs and ensuring all staff were treated equitably.  

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The importance of effective governance systems was not fully understood and meant systems were not always in place which led to a lack of oversight of people’s care and maintaining a safe environment. Some audits were in place; however, they failed to identify the concerns we found and were therefore ineffective. For example, audits of care plans had failed to identify all the inconsistencies. The providers health and safety audits had not identified these issues and risks. Infection prevention control (IPC) audits were not effective as they had not identified the concern we found. Additionally, when incidents or accidents had occurred, these were recorded however, they were not always investigated or reviewed to identify any learning that was needed. There was no overall analysis of the incidents which occurred so trends could be considered. Health and safety audits had not identified risks in relation to IPC and other issues.  However, the provider was able to evidence their audits of call bells ensured people received support when needed. 

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. Partners told us the registered manager was responsive. The provider worked in partnership with other agencies to ensure concerns were addressed in a timely manner.  Systems were in place to ensure the provider worked in partnership to ensure people received the support they needed.  

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.  Systems did not effectively identify concerns and drive improvements within the home, which meant learning opportunities were missed. For example, when incidents and accidents occurred, these were not always reviewed so lessons could be learned. On the first day of the inspection, we raised our concerns to the registered manager about cleanliness and hygiene practices within the home, and they acknowledged this, explaining they did not have enough domestic staff working at the time. However, when we arrived for the second day of our inspection, 6 days later, we found the provider had not acted and our concerns had remained. In other areas the provider had focused on learning and had implemented a new training system, including a very comprehensive suite of mandatory and role specific training for staff.