CQC report explained · a residential care home
What the CQC found at Riverside Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Inadequate and placed in special measures; inspectors found serious safety and leadership failures.
This was an unannounced focused inspection. Inspectors visited on 7, 12 and 28 September 2023, and reviewed safety and leadership because of concerns about safeguarding and a possible closed culture. They spoke with people, relatives and staff, and checked care, medicine, staffing and management records.
The home was not safe. Risks were not properly assessed or managed, fire and water safety actions were incomplete, the building was not secure, infection control was unsafe, medicines were not always stored or recorded safely, and safeguarding concerns were not always handled promptly. Staffing levels and staff training were also not always adequate.
The home was not well-led. Quality checks did not find most of the problems, important notifications had not always been sent to CQC, and people and relatives were not given formal ways to help improve the service. The manager acted quickly after inspectors raised concerns, including starting provider audits and moving to an electronic medicines system.
The overall rating fell from Good at the previous inspection, published on 8 January 2021, to Inadequate. The home is in special measures, so CQC will monitor it and normally re-inspect within six months to check for significant improvement.
Kind and familiar staff
People and relatives spoke positively about the staff. Inspectors said staff knew people well, and people felt supported.
“Staff knew people well and people told us they felt well supported.” from the report
Responsive manager
The manager acted promptly after inspectors raised concerns and began steps to reduce risks and improve oversight.
“The registered manager was responsive to our feedback and took immediate action to engage with local safeguarding teams and to improve staff understanding and knowledge in this area.” from the report
Good communication
Relatives said communication was good and that they were kept informed. They could speak with the manager when needed.
“Relatives told us communication was good, and they were kept up to date.” from the report
Person-centred areas
Some care plan information was personalised. People’s rooms and shared areas were clean and personalised.
“Some areas of people's care plans were person-centred.” from the report
Support with choice
Inspectors found that people were supported to make choices where possible and that legal safeguards were in place when needed.
“People were supported to have maximum choice and control of their lives” from the report
Unmanaged safety risks
seriousImportant risks, including self-harm, access to stairs, skin damage, fire and hot water, were not consistently assessed or dealt with. Inspectors said people were at risk of harm.
“Risks to people were not appropriately assessed, monitored and managed.” from the report
Unsafe medicines and infection control
seriousSome medicines were not securely stored and records were incomplete. Laundry and basement areas were dirty, and infection control practices were unsafe.
“Medicines were not always managed safely. This placed people at risk of harm.” from the report
Safeguarding weaknesses
seriousConcerns about possible abuse were not always raised or investigated promptly, and some required referrals and notifications were not made.
“Safeguarding concerns were not always raised or investigated in a timely manner.” from the report
Insufficient staffing
seriousStaff absences were not always covered, staffing levels were not based on a robust assessment, and some people reported difficulty getting help at night.
“There were not always sufficient numbers of suitable staff to support people's needs.” from the report
Weak management checks
seriousThere were no formal provider audits, and existing checks failed to identify most of the problems found by inspectors. People and relatives also lacked meaningful formal opportunities to give feedback.
“Systems were not in place to adequately assess, monitor, and improve the quality and safety of the service.” from the report
- 01What evidence can you show that individual risks, including falls, self-harm, access to stairs and skin damage, are now assessed and reviewed?
- 02How are medicines now stored, administered and recorded, including creams, controlled drugs and 'when required' medicines?
- 03What staffing levels are planned for each shift, especially at night, and how will absences be covered?
- 04What has been done to complete the fire safety actions, update safety checks and secure access to the building?
- 05How are safeguarding concerns, incidents and complaints now reported, investigated and shared with the right organisations?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 4 November 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, January 2021
Riverside Court was rated Good; inspectors found safe, kind and well-organised care, with the manager's registration still in progress.
The inspection was unannounced and took place on 19 November 2020. Inspectors spoke with people, relatives, staff, the provider and the cook. They observed care, checked the building and reviewed care, medicine, staffing and management records.
The inspection was prompted by concerns about nutrition, hydration and pressure care. Inspectors found no evidence that people were at risk of harm from these concerns. They found clean surroundings, enough staff, safe medicine systems, suitable care plans and effective infection control during the pandemic.
People and relatives said people felt safe and well cared for. Staff were described as patient, kind and respectful. The home was rated Good overall, with Good ratings for Safe, Effective and Well-led.
Infection control
Inspectors found the home was clean and had suitable measures to prevent and manage infections, including during the coronavirus pandemic.
“All areas were clean, tidy and there was sufficient cleaning taking place to keep people safe from the risk of infection.” from the report
Safe staffing and medicines
There were enough staff to meet people's needs, and inspectors found medicine records were complete and medicines were given at the right time.
“Medicine administration records (MARs) were clear and completed fully. People received their medicines as prescribed, at the right time.” from the report
Kind, person-centred care
Staff spent time talking with people and provided care in a patient, respectful and dignified way.
“Staff were patient, kind and respectful towards people. Care was person-centred and staff had time to organise activities and talk with people during the day.” from the report
Support with food and health
People's food and drink needs were met. The home sought professional help when people needed support with their weight or health.
“People's nutrition and hydration needs were met, and people were provided with a varied and nutritionally balanced diet.” from the report
Manager's registration
needs fixingThe manager was not registered with the CQC at the time of the inspection. The report says the registration process had begun, but families should check its current position.
“The manager in place wasn't registered with us. However, steps had been taken to begin the registration process.” from the report
- 01Has the manager now completed registration with the CQC, and if not, what is the current position?
- 02How are you continuing to monitor people's nutrition, hydration and pressure care after the concerns that prompted this inspection?
- 03How will you keep relatives informed about visiting, infection control and contact arrangements?
- 04How often are care plans and risk assessments reviewed when a person's needs change?
- 05How do you check that staff have enough time to support people with activities and conversation as well as personal care?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 8 January 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 Riverside Court
7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- November 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- January 2021Goodstayed GoodSafe: GoodWell-led: Good
- August 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Inadequatedown from Requires improvementSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 16 March 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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28 live-in carers within about an hour of North Yorkshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.