CQC report explained · a residential care home
What the CQC found at Riversdale Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rated Good; inspectors found safe, kind care and better management, but recommended that some fire doors are checked.
This was an unannounced focused inspection on 31 May and 3 August 2023. One inspector spoke with people, relatives and staff, and checked care records, medicines records and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough suitable staff, safe medicines systems, thorough risk assessments, good infection control and effective checks on care quality. People and relatives said they felt safe and listened to.
Inspectors found that some fire doors had significant gaps at the bottom. They recommended that competent people assess the doors. This was a recommendation, not a breach of regulations.
The previous rating was Requires Improvement, published in October 2021. The provider had completed an improvement plan. Inspectors found enough improvement for the home to be no longer in breach of Regulations 12 and 17, and the overall rating changed to Good.
People felt safe
People and relatives told inspectors they felt safe. Inspectors also found that safeguarding arrangements and staff knowledge were in place.
“People and their family members told us they felt safe at the home.” from the report
Thorough risk planning
Risks linked to people's care were assessed clearly. Plans supported people to stay safe while keeping as much independence as possible.
“The risk assessments in place were person centred, thorough and gave clear information for staff on how to support people to reduce these risks.” from the report
Medicines were managed safely
Inspectors found person-centred medicines plans, regular checks and safe management of controlled medicines.
“People's medicines were safely managed at the home.” from the report
Warm relationships and culture
People appeared relaxed and comfortable. Inspectors found positive relationships between people and staff, and relatives said they felt involved.
“There was a warm, friendly and good-humoured atmosphere at the home.” from the report
Learning from incidents
The home investigated accidents and incidents in detail and looked at how to prevent similar problems happening again.
“These investigations were detailed and thorough and focused on any possible contributing factors such as communication, actions taken by staff and management response to the incident.” from the report
Fire-door gaps
needs fixingA few fire doors had significant gaps at the bottom. Inspectors recommended that competent people assess them to make sure they are safe.
“A number of fire doors had been refurbished. However, a few fire doors had significant gaps at the bottom of them.” from the report
- 01Have the fire doors with gaps now been assessed by competent people, and what work was needed?
- 02Has the new manager's application to register with the CQC been completed?
- 03What checks are now used to make sure risk assessments and medicines records remain up to date?
- 04What improvements from the previous action plan are still being monitored?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 1 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2021
Rated Requires Improvement; inspectors found risks in medicines, care records and governance, although people said they felt safe.
This was an unannounced focused inspection on 16 September 2021. One inspector and one Expert by Experience spoke with people, relatives, staff and health professionals. They reviewed care records, medicines records, staff files and management records.
The home did not always manage medicines safely. Care plans and risk assessments were not clear or kept up to date. Records did not always show that people's health needs, pressure area care, weights or fluid intake were being monitored properly. Inspectors said these issues placed people at risk, although they found no evidence that anyone had been harmed.
The home had systems for dealing with accidents, safeguarding concerns and complaints. Infection control arrangements were found to be suitable. Inspectors also saw warm and respectful relationships between staff and people living in the home.
The overall rating changed from Good at the previous inspection to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other three areas were not inspected and their previous ratings were used in calculating the overall rating.
People felt safe
People spoken to by inspectors said they felt safe in the home and had no concerns about staff or the environment.
“I feel safe as there are staff always on hand.” from the report
Kind relationships
Inspectors saw permanent staff communicating warmly and respectfully with people. Staff knew people's personalities, likes and dislikes.
“Observations of staff indicated warm and caring relationships had developed with people living in the home and interactions were respectful and familiar.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including the use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open management
The management team engaged positively with the inspection and acted on feedback given during the visit.
“The management team were open and transparent and engaged positively in the inspection process.” from the report
Medicines guidance
seriousGuidance was missing for creams, patches and medicines given only when needed. Inspectors found that patches and topical medicines were not managed in line with guidance.
“Appropriate guidance in relation to 'as and when needed' and topical medications were not in place.” from the report
Incomplete care records
seriousCare plans and risk assessments did not clearly describe people's current needs or how staff should provide care. Records also did not always show that pressure care, weight changes or fluid intake were properly monitored.
“Care plans and risk assessments did not reflect people's current needs.” from the report
Weak quality checks
seriousThe home's audits did not consistently identify problems with medicines, care planning and health monitoring. This led to a breach of the good governance regulation.
“We found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate good governance.” from the report
Recruitment records
needs fixingCriminal record checks were present in the three staff files reviewed, but suitable references were not always in place before staff started work.
“We recommend the provider consider current guidance on appropriate recruitment processes and take action to update their practice accordingly.” from the report
Communication with families
needs fixingSome feedback suggested that communication with families was not always strong, including communication about the change of provider.
“The home has changed hands although I was never told officially, and I think that the new manager is trying to get things sorted but their communication could be better.” from the report
- 01What changes have been made to the guidance for creams, patches and medicines given only when needed?
- 02How do you now check that care plans and risk assessments reflect each person's current needs?
- 03How do you record and review pressure area care, weight changes and daily fluid intake?
- 04How do you check that medicines and care records are being managed safely through your audits?
- 05How will you improve communication with relatives, including telling them about important changes to the home?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 12 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Riversdale Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2021Inspected but not ratedSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 27 June 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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