Archived: Riverside House

The inspection took place on 29 September 2016 and was unannounced. We last inspected this service on 24 February and 27 May 2016 where two breaches of legal requirements were found. After the comprehensive inspection, the provider told us what they would do to meet legal requirements in relation to safe care and treatment and good governance. We undertook this focused inspection to check that they had followed their plan and to establish if they were now meeting legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Riverside House on our website at www.cqc.org.uk

There was no registered manager in post at this inspection, but a new manager had been appointed and was in the process of registering with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection, there were a number of safeguarding issues which were being investigated by the local authority. We received feedback from the local authority safeguarding and contracts teams prior to this inspection, and both departments reported that significant improvements had been made in respect of the service delivered.

We checked the management of medicines and found that these were being managed safely. We looked at medicine records and found that these were complete and legible. A pharmacist who provided support to the service following our last inspection, told us that the provider had made the necessary changes to systems and auditing processes to ensure medicines were administered safely.

During the last inspection we found high levels of agency staff were used and we recommended that this was kept under review. At this inspection we found that a number of new staff had been recruited and the use of agency staff had significantly reduced.

We checked the premises and found that new flooring had been provided and the odour issue evident at the previous inspection was significantly improved. There remained some mild malodour in one room but this was being addressed by the manager. A number of improvements to the environment were noted during this inspection. A room in the centre of the first floor had been refurbished to make a welcoming seating area with a television and comfortable chairs.

At the last inspection we found that suitable checks on the safety of the premises were carried out and that emergency contingency plans were in place. We did not look at all of these checks again during this inspection. All of the showers and the bath which had been out of order, had now been fixed, although the bath was temporarily out of use again as it was awaiting a new part and it was fixed the following day.

During this inspection we found that individual risks to people had been identified and plans were in place to address these. Risk assessments had been evaluated regularly. The sensor mats we saw which were in place to help to prevent falls, were plugged in and placed appropriately. Moving and handling assessments had been carried out and appropriate care plans were in place. Staff had received training in the safe moving and handling of people, as this had been a concern which was raised following our findings at our last inspection.

We found shortfalls in the recording of food and fluid intake at the last inspection, which meant it was difficult for staff to identify, and take steps to reduce the risk of malnutrition and dehydration. At this inspection we found assessments of the risks of inadequate dietary and fluid intake had been carried out, and care plans were in place. Food and fluid charts were completed, and there was a clear protocol to follow in the event that a person did not reach their target intake. Weights were recorded and monitored.

We checked people’s care records and found that people had been seen by a variety of health professionals. Bespoke training took place on the day of the inspection which was designed to assist staff in how to identify the causes of behavioural disturbance and distress, and support people at these times.

We saw an improvement in the standard of care planning documentation during this inspection, although this was work in progress. Detailed audits of care plans had taken place and managers were aware of areas that required further development and plans were in place to address these. There was also in improvement in care plan evaluation dates which we found were up to date.

A complaints procedure was in place, and there had been no formal complaints since the last inspection. A new manager was in post who was in the process of registering with CQC. They had previously worked in the service as a deputy manager and visitors and staff told us that they felt the appointment of the new manager, and input from regional managers, had resulted in improvements to the service. Staff also told us they thought that morale in the service was improving amongst staff due to consistent staffing and a period of stability in the management team.

We checked systems in place to monitor the quality and safety of the service. We found that governance arrangements had improved. The manager told us, and we observed, they had carried out regular checks, and daily management reports were submitted to the senior management team.

We have not changed the rating of the home at this inspection. This was because we wanted to be reassured that improvements made would be sustained over a longer period of time.

The inspection took place on 24 February and was unannounced. Following the inspection, we were made aware of a number of concerns and we revisited the service for a second date on 27 May 2016.

We last inspected the service on 07 May 2014 and the service met all of the regulations we inspected at that time. A new manager had been appointed since the previous inspection and was in the process of registering with CQC on the first day of the inspection. The manager had resigned before the second day of the inspection and an interim manager from one of the provider's other homes had been appointed to manage the service.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People told us they felt safe. There were safeguarding policies and procedures in place and staff knew what action to take if abuse was suspected. They had received training related to the protection of vulnerable adults. There were a number of safeguarding concerns under investigation at the time of the inspection and we will report on the outcome of these once investigations are completed.

We checked the management of medicines and found that systems for the administration and management of medicines were not being followed by all staff. A community pharmacist had audited medicines and had developed an action plan for improvement with the provider. They were continuing to work with the service to support them to make the required improvements.

We found suitable numbers of staff on duty on both days of the inspection but a number of staff had left the service and there was a reliance on use of agency staff although this had reduced. We made a recommendation to continue to monitor staffing numbers and skills mix while recruitment was on-going.

One the first day of the inspection we noted mild malodour in a small area of the home and the manager advised that plans were in place to address this. On the second day of the inspection, we found that this had deteriorated. Attempts had been made to clean the carpets but this had been ineffective. No action had been taken to replace the flooring. We found that infection control procedures were not followed and that there were damaged and marked mattresses and bed covers which posed an infection control risk.

Environmental audits and risk assessments were carried out and safety checks of the building and equipment were completed on a regular basis. These had not highlighted that a number of showers were broken and one bath was out of order. Emergency contingency plans were in place in the event of damage to the building or due to inclement weather such as flooding.

Individual risk assessments were carried out and action had been taken to mitigate risks, such as the provision of falls sensor mats for people identified to be at high risk of falling. Sensor mats alert staff when a person is moving unsupervised. A concern was raised that sensor mats were not always plugged in and in use and that people did not always have access to call bells. Steps were in place to address this issue.

Moving and handling assessments and care plans were in place but an assessment carried out by an occupational therapist found that staff were using unsafe moving and handling techniques and incorrect equipment with two people. This was reported to the provider for immediate action and the new equipment was ordered and care plans updated.

On the first day of the inspection we found that staff had received training in a number of key areas and we were told that plans were in place to address identified gaps in training.

Safe recruitment procedures were followed which meant that people were protected from harm. Systems for supervision and appraisal were in place which meant that the support and development needs of staff were identified.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. The registered manager had submitted DoLS applications to the local authority for authorisation. Assessments of mental capacity had been carried out and where possible, people contributed to discussions and decisions about their care.

People were not always adequately supported to eat and drink. Nutritional assessments were carried out, and people's weights were monitored to enable referrals to be made for specialist support if necessary. On the second day of the inspection we found some gaps in the evaluation of nutrition care plans, but these had begun to be completed again. Fluid balance charts were completed but where people had failed to reach their target fluid intake there was no evidence of action taken to ensure their hydration needs had been met. We saw that regular drinks were offered to people but charts did not demonstrate that the hydration needs of people were being monitored or met.

People had access to a number of health care services including the dentist, podiatry, and district nursing. One relative had expressed concern about the time it took to arrange appointments which they said needed several reminders. Another relative told us they found that appointments were made promptly. The manager said they would monitor this.

People, relatives and a visiting professional told us that the service was caring. We saw that staff treated people kindly and respectfully and there was a good deal of humour between staff and people during the inspection. Staff appeared to know people well and supported them to maintain their hobbies, interests and independence, including, for example, participating in voting in local elections. We judged however that allowing people to be exposed to extreme malodour in some cases, over a prolonged period of time, compromised their dignity. We also found that a lack of timely response to difficulties in supporting a person with personal care needs also compromised their dignity.

A range of activities were available and an activities coordinator was in post. People, relatives and staff spoke highly of the activities coordinator who demonstrated a good understanding of the use of activities as a therapeutic intervention [to distract or to evoke memories] in addition to entertainment. There were links with the local community including access to poetry and drama groups, and links with local churches.

There was a complaints procedure in place which was prominently displayed. On the first day of the inspection, we saw that two complaints had been received and these had been addressed and responded to appropriately. A further complaint had been received and was in the process of being investigated on the second day of the inspection. There were a number of feedback mechanisms to obtain the views from people, relatives and staff. These included meetings and surveys. Feedback from relatives showed mixed views about the quality of the service.

On the first day of the inspection, people, relatives and staff spoke highly of the new manager and commented upon the positive changes she was making. On the second day of the inspection we found concerns in relation to the management of the service. Effective systems were not in place to monitor the quality and safety of the service.

Systems for the on-going monitoring of the service needed to be strengthened to ensure areas of non-compliance with policies and procedures were picked up promptly to keep the number of issues to a minimum including in the absence of a registered manager. The manager and regional manager were aware of this and the need to strengthen these systems.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We found the premises were designed to provide a safe environment and arrangements were in place to ensure the home and gardens were maintained to protect people from the risks of unsafe or unsuitable premises.

The provider had in place effective systems to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

We saw risk assessments had been completed for people who were assessed as being at risk of falls.

Is the service effective?

People's health and care needs were assessed and they were involved in this process. We saw that particular needs were identified for example, dietary needs or dementia care in individual's plans.

Staff training is provided that takes account of the needs of the people in the home. For example, we saw training in dementia and administration of medicines had been provided.

People were supported to be able to eat and drink sufficient amounts to meet their needs. The menus provided a varied selection of food and people were afforded choice about their meals.

Is the service caring?

We saw staff responded kindly and promptly to people. Care workers were patient and encouraging to people as they assisted them. People told us, 'It's very good here. The staff are so nice. I can choose my own routine' and 'The staff are really good and I feel at home here. They are there when I need them and I feel safe here having them around to assist me.'

People's preferences, interests, aspirations and diverse needs were recorded and we saw staff were aware these during the inspection.

Is the service responsive?

We saw evidence that the care staff identified changes in people's needs and acted to make sure they received the care they needed. For example, there was evidence that loss of weight was communicated to the cook quickly so that they were able to ensure people received a fortified diet.

People told us they were aware of the complaints procedure and staff could describe how they would assist a person to make a complaint. We saw there were systems in place for dealing with and recording complaints.

Is the service well led?

The staff we spoke to were all aware of the complaints, safeguarding and whistle blowing procedures. All of the staff said they would immediately report any concerns they had about poor practice and were confident these would be addressed.

The service had a quality assurance system in place that included the use of surveys from people who used the service. This meant people were able to feed back on their experience and the service was able to learn from this.

Staff had regular supervision, appraisals and staff meetings which meant they were able to feedback to the management of the home their views and suggestions. Staff we spoke with confirmed their views were listened and account was taken of them. They said they felt well supported by the management of the home.

We found that people's care and support needs were appropriately assessed, their care needs were planned and their individual care needs were met. People said the staff were very caring and looked after them well. Comments included, "The staff are very good, always there to help" and "The manager and staff are very approachable if I have a problem". We concluded that people's care needs were assessed and care and treatment was planned and delivered in line with their individual care plans.

We looked at the system for dealing with medicines and concluded that appropriate arrangements were in place.

We found there were effective recruitment and selection processes in place so appropriate staff were employed to care for people who used the service.

We spoke to seven people who told us they knew how to make a complaint and felt their comments would be taken seriously and investigated. They all said they had never needed to complain because they felt they were well looked after. We concluded people had their comments and complaints listened to, and acted upon, without the fear they would be discriminated against for making a complaint.