We undertook an unannounced focused inspection of River View Care Centre on 3 December 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our September and October 2018 comprehensive inspection had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This is because the service was not meeting eight legal requirements at their last inspection.

No additional risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity, so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

River View Care Centre is a care home with nursing, which provides services across three floors that are further split into seven units. The care home specialises in providing a service to older adults who may be frail due to age or disability as well as individuals living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service is currently registered to provide accommodation to a maximum of 137 residents. Following the last inspection rating of Inadequate, the service was placed in special measures. A restriction was placed on new admissions, which meant the service was unable to accept any new people to River View Care Centre. CQC imposed a further three conditions on the service. Two of these were met within the stipulated time frame. One condition remains outstanding, with the Commission accepting the reason presented for the delay. The restriction on admissions remains in place until agreed otherwise by CQC.

The service has a registered manager. A registered manager is a person who has registered with CQC 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 2008 and associated Regulations about how the service is run.’

The service remained unsafe. People were not kept safe from the risk of harm. Documentation was poor and conflicting in information, and staff were unable to provide assurances as to their understanding of the individual risks associated with people's care and support needs.

People were not appropriately monitored for adequate food and fluid intake and weight checks. As a result, potentially people did not have referrals made to external professionals in a timely way. Where bedrails were required to keep people safe, these were not always used. Staff attended to people, but failed to recognise the risk the lack of bedrails presented.

Staff were unaware of people’s changing health needs. Documentation, although stated as reviewed and therefore up to date, was inaccurate and not reflective of people’s needs. This meant that people were potentially exposed to unsafe care and treatment.

Governance of the service remained inadequate. Current systems and processes used as part of the audit process by the service were not effective in monitoring, assessing and improving the quality of the service. Where audits had been carried out in relation to people's care plans and risk assessments, these had failed to identify inaccurate and misleading information.

Poor staff knowledge of people and safe practice, in addition to inaccurate documentation, raised concerns in relation to staff professionalism. These issues were discussed during the inspection with management.

The service remained in breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 20

This inspection was completed on 24, 25 September and 2 October 2018. A follow up visit took place on 17 October 2018. This was a comprehensive first inspection for the new provider. Any newly registered service required inspecting within 12 months from registration to ensure they are compliant with regulations.

The service was taken over by MMCG (2) Limited in August 2017, prior to which the care was provided by another service provider. Some of the previous staff transferred as part of the acquisition, however, some previous members of senior management within the service left.

River View Care Centre is a 137 bed service that provides facilities over three floors to older adults with varying needs, including living with dementia. The service is broken down into seven units, that are distributed as: two on the ground floor, three on the first floor and two on the second floor. River View Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. MMCG (2) Limited are responsible for the operation of the service, with Lifestyle Care Management Limited holding responsibility for the property. During the first two days 115 people used the service. By the third day the numbers had reduced to 113. Two people on end of life care passed away during the inspection process.

A registered manager had been in post since the service was taken over by MMCG (2) Limited. The manager was previously registered with the CQC in April 2017, under the old provider, with a new application since made by the new provider. 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 2008 and associated Regulations about how the service is run.

The service was rated Inadequate.

People were not kept safe. Risk assessments and comprehensive documentation was not in place to ensure people were offered responsive safe care and treatment. Care plans contained minimal information, with crucial information missing. The lack of information meant people were put at risk of harm.

Medicines were not always managed safely. Whilst we found that medicines were generally stored safely and appropriately administered, guidelines were not in place for two people who were given medicines covertly. Nurses spoken to were unclear of the correct protocol that was to be followed prior to covert medicines being administered.

People were not being kept safe due to a failure in appropriate monitoring and recording of the environmental risks and risks to people. A leak in the roof gave cause for serious concern around safety to people and staff. The service did not have robust recruitment processes in place, to ensure staff employed were safe to work with people.

Staff did not appropriately record information. Incidents were not always reported or understood to be reportable, therefore information was not accurately updated in daily records. Nutrition and hydration records were maintained for all people; however information was not cross referenced or analysed as required. As a result some referrals were not made to health professionals to seek further clarity on change in people’s hydration and nutrition.

Neither the provider nor the registered manager had effective systems in place to audit care documentation. Such systems would monitor the care provided in relation to the care plans, therefore highlighting any errors as and when these were occurring. This was specifically important given the number of discrepancies noted between day and night records.

People's care was not always delivered in a dignified way. Their independence was not promoted nor their pr