This was an unannounced inspection which took place on Friday 20 January 2017. It was carried out by an adult social care inspector, a specialist advisor and an expert by experience.

Riverside Court Care Home is a purpose built residential and nursing home situated on the harbour side of Maryport in Cumbria and is within walking distance of the local amenities of the town. Accommodation and communal space is over two floors and all rooms are for single occupancy and have en-suite facilities. There are suitable shared areas and a secure garden. The home provides accommodation for up to 60 older people some of whom may be living with dementia. There were 57 people living at the home when we visited.

The service is run by Tamaris Healthcare (England) Limited. This is a subsidiary of Four Seasons Healthcare and it is run using the staff and the systems of Four Seasons Healthcare.

The home had a suitably qualified nurse who had been the registered manager since May 2016. 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.

We last inspected this service on 20 and 21 August 2015 where we judged the service to be rated as 'Requires Improvement'. There were no breaches of the regulations at this visit in 2015 but we made recommendations about the application of emollient creams, communication and working with people living with dementia. At this visit we judged that good progress had been made in all these areas.

The staff team understood how to protect vulnerable adults from harm and abuse. Staff had received suitable training and showed a sensitive and practical approach to any concerns. Good risk assessments and risk management plans were in place to support people. Suitable arrangements were in place to ensure that new members of staff had been suitably vetted and were the right kind of people to work with vulnerable adults. Any accidents or incidents had been reported to the Care Quality Commission (CQC) and suitable action taken to lessen the risk of further issues.

The home had increased the staffing levels and the registered manager was keeping this under review as people's dependency changed. Staff were suitably inducted, trained and developed to give the best support possible.

Medicines were appropriately managed in the service with people having reviews of their medicines on a regular basis. People in the home saw their GP and health specialists whenever necessary.

The registered manager was aware of her responsibilities under the Mental Capacity Act 2005 when people were deprived of their liberty for their own safety. We judged that this had been done appropriately and that consent was sought for any interaction, where possible.

People told us they were happy with the food provided. We saw that the staff team made sure people had proper nutrition and hydration. We noted that snacks and drinks were available for people to help themselves.

Riverside court was a purpose built nursing home and the new manager had ensured that the environment was as homely as possible. There were nice touches around the home that made the environment comfortable for people living there. There had been redecoration in all areas and things like floor covering and furniture had been replaced as necessary. The provider had replaced some windows with more refurbishment work planned. The registered manager had plans to improve the outside space by creating a hen run, a vegetable garden and workshop/shed for people to spend time in.

We observed kind, patient and suitable care being provided. Staff made sure that confidentiality, privacy and dignity were adhered to. People were encouraged to be as independent as possible. Staff were trained in end of life

The home made use of the local community as a valuable resource and people in the home benefitted from these close links and support with the community. The people we spoke with said they were happy with the care and support they were receiving and told us they were well treated by the staff. They told us there was always plenty of staff on duty and they found them responsive to their needs and were kind and patient. One person told us, “You don’t get the chance to get bored here.”

We found the service to be appropriately staffed for the needs of the people living in the home. The staff team were experienced and well trained with specialist skills in caring for people with dementia. The home had developed a good working relationship with the local healthcare teams in order to ensure people had access to expert healthcare advice. The local social work team reported an improved working relationship with the home.

The organisation had good systems in place to ensure standards of care were maintained and we saw that the team monitored quality, consulted the people in the home and made improvements as necessary.

Overall we judged that the new manager had continued to improve the quality and the delivery of care offered to people in the dementia units through targeting staffing arrangements, training, and improving the environment. All these measures had helped to increase people’s choice and involvement in their care.

At our inspection of this service on 1st November 2012 we found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage them.

Following our inspection the provider wrote to us and told us that they would review the way medicines were managed and this would be achieved by 28 February 2013.

As part of this inspection we looked at medicines records, supplies and care plans relating to the use of medication. We found that people who used the service received their medicines at the times they needed them and in a safe way.

When we spoke with people they told us they were happy with the support they received with their medication. People told us:

“All the girls are lovely and look after me”.

“I always get my tablets morning, lunchtime and evening”.

“Staff stand there while I take them [tablets]”.

“They don’t like you missing your tablets”.

We saw very good records of communications between staff and healthcare professionals. Medicines were prescribed and given to people appropriately. There were appropriate arrangements in place in relation to the recording of medicines. We saw weekly audits, or checks, of medication handling. Staff told us that they had regular meetings to discuss medication handling and to manage issues that arose from audits to improve the quality of medicines management.

Overall, we found that medicines were managed in a safe way.

On this inspection we concentrated on the dementia care units as this is where the need to make the most improvements was identified at the last inspection.

We observed an activities session and lunch time on both dementia units.

Some of the people we saw in the dementia care units had fairly advanced dementia however we did speak to a number of people who had conversations with us.

We also observed from body language, that people responded well to the staff on duty. One person we spoke with said “Its like a hotel here- I can have a cooked breakfast and the dinners are always good. They always give you a choice”.

The activity session involved using a large colourful parachute with 5 residents who looked to be having a great deal of fun, with lots of laughter and lively conversations between residents, staff and visiting relatives.

Overall the people we spoke to were complimentary about their care.

During our visit to Riverside Court we spoke to people living in all areas of the home.

The people we saw in the dementia care units had fairly advanced dementia and only one or two wished to engage in conversation. However, we observed from body language, that people responded well to the staff on duty.

One of the people we spoke to during our visit told us that they were ‘well looked after’. They had been ‘very poorly’ and were now ‘on the way to recovery.’

Another person told us that staff adhered to their wishes regarding elements of their personal care support.

We spoke to people about the food at the home. They told us that the food had improved recently but that there were now less choices available. Another person said ‘we have really good dinners, especially on Sunday’.

Most of the people we spoke to told us that they were ‘happy’ or ‘satisfied’ with the service.

People told us that they were 'asked about the care and support they would like' before they came to live at the home. People confirmed that end of life plans had been discussed with them. This is a particularly sensitive subject and they did not wish to discuss these matters further with us.

Relatives told us that their relative is not always able to make decisions for themselves. They told us that the manager and staff at the home have included them in decision making processes and in the preparation of care plans to help ensure their relatives wishes and needs are met.

One of the people we spoke to told us that there were 'activities in the home' but that they 'choose not to join in' and that this is respected.

One of the people we spoke to told us that the food was ‘alright’ but missed ‘proper fish and chips’.

Another person said 'the food is OK and I can have a cooked breakfast if I want. There are plenty of choices for meals and I get sufficient portions.' This person was waiting for their morning coffee to arrive, they added 'although there are set times for drinks and snacks, you can have something when you want’.

One person told us that staff were’ generally OK’ and would help if asked. They also said that some staff were ‘not so nice as others’ but declined to provide us with any further information.

One person told us that they were asked about the care and support they would like before they came to live at the home. However, they did not know that they had care records kept about their needs.

A relative told us 'staff ensure our relative is always given choices and that their wishes are respected.'

This was an unannounced inspection that took place on 20 & 21 August 2015. We carried out this inspection to check that improvements had been made following our previous inspections of the 23 & 24 February 2015. The findings of these previous visits led us to rate the home as inadequate as the provider failed to meet all the requirements of the regulations.

At the inspection in February 2015 we found the home was in breach of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010:

Regulation 9: Care and welfare of service users

Regulation 10: Assessing and monitoring the quality of service provision

Regulation 11: Safeguarding of people who use services from abuse

Regulation 13: Management of medicines

Regulation 14: Meeting nutritional needs

Regulation 16: Safety, availability and suitability of equipment

Regulation 18: Consent to care and treatment.

Regulation 19: Complaints

Regulation 20: Records

Regulation 21: Requirement relating to staffing

Regulation 22: Staffing

Regulation 23: Supporting workers

In addition the home was failing to notify us of events they are required to by law. Which was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009: Notification of other incidents.

The above regulations have now been replaced with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We had asked the provider to make improvements in meeting people’s health and welfare needs, records, nutrition needs, safeguarding, safety and suitability of equipment, assessing and monitoring the quality of service and completing statutory notifications appropriately. We received an action plan from the provider detailing how these improvements would be made. We received regular updates on progress towards meeting these improvements.

At this inspection of 20 & 21 August 2015 we looked at all the areas where the home had breached the regulations set out above, and other areas to ensure that we carried out a fully comprehensive inspection. We found that there had been improvements across all areas that we looked at.

We found that the home was no longer in breach of the above regulations.

Tamaris Healthcare (England) Limited is a subsidiary of Four Seasons Healthcare and it is run using the staff and the systems of Four Seasons Healthcare. We will refer to the organisation running the home as Four Season Healthcare (FSHC) throughout this report.

The provider, had after the last inspection, ensured that support had been made available to assist the home in meeting safe standards of care through improved quality monitoring and input from senior managers within the organisation.

Since the last inspection a new interim manager had been appointed and plans were in place for them to become registered 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 2008 and associated Regulations about how the service is run.

Riverside Court Care Home is a purpose built residential and nursing home situated on the harbour side of Maryport in Cumbria and is within walking distance of the local amenities of the town. Accommodation and communal space is over two floors and all rooms are for single occupancy and have en-suite facilities. There are suitable shared areas and a secure garden. The home provides accommodation for up to 60 older people some of whom may be living with dementia. There were 47 people living at the home when we visited.

On this inspection in August 2015 we found that people’s care and health needs were being met. People looked well cared for with good attention to detail to ensure people were well dressed and to their own taste. We saw staff being attentive and considerate to people’s needs and feelings. Call buzzers were answered promptly, and everyone we spoke to said they were well cared for by staff that were kind and caring.

We judged the home to be safer because the provider had ensured that all staff had been given training to identify and report any potential harm or abuse of vulnerable adults. We had evidence to show that senior staff understood how to report, and where appropriate, manage any issues related to possible abuse.

Risk assessments related to the environment and the delivery of care were up to date. Accidents and incidents were managed correctly and reported to the appropriate authorities, including ourselves, CQC.

The home was now staffed to safe levels that gave care to people in a timely way from staff that were well led and suitably trained and experienced in meeting people’s needs.

Since the last inspection new staff had been recruited at all levels, including general nurses, mental health nurses, care staff and other support staff. A new interim manager and a new deputy had been recruited.

These new staff were recruited safely and disciplinary action had been taken when staff were not fulfilling their job role.

We saw that the way staff were being utilised and deployed in the home had improved, with the addition of a senior care worker on each shift. We saw how these senior staff were giving more of a lead and direction to staff to ensure people’s needs were met in an orderly and timely manner.

We found that the provider had significantly improved the way medicines were managed. People received their medicines at the times they needed them and in a safe way. We did however find the way people’s creams were managed required improvement.

We recommend that the service consider how they ensure that people are receiving appropriate support with the application of emollient creams and how this may be more accurately recorded.

Infection control measures in the home were good. The staff team had been suitably trained and had access to personal protective equipment. The home was clean and orderly.

All new staff had received induction training. This had been followed up by training in all the core subjects the provider felt the team needed. Some staff had received further specialist training.

Staff told us they now received good levels of both formal and informal supervision which had helped them to develop. Staff said that communication at all levels had improved.

A new style care plans had been introduced which were intended to make people’s needs clearer to staff and easier to monitor people’s changing healthcare needs. We found that these were still a “work in progress” as staff needed time to familiarise themselves with how they worked. We saw that as each person’s new plan was introduced that that people were becoming increasingly more involved in them.

We saw that for some people with more complex communication needs that staff were having difficulty in communicating with them effectively.

We recommend that the service seek advice and guidance from a reputable source, about supporting people to communicate and express their views.

We saw that good nutritional planning and practice was now in place. People who had been quite seriously underweight at our last visit had put on weight and were no longer undernourished.

People we spoke to were happy with the food provided. We observed mealtimes being much more orderly and staff were spending time and giving appropriate support and care to those people who needed more help.

We saw evidence to show that the staff team sought support and advice from local GPs, community nurses, dieticians and mental health workers to promote people’s health and well-being.

Healthcare and social services professionals told us that they had seen a marked improvement in the care and treatment of people in the home, and in the way people’s healthcare needs were being managed.

However, we found that overall the home lacked a cohesive strategy for supporting people living with dementia for whom a consistent approach is essential.

We recommend that the service develops a dementia care strategy for the home, based on current best practice, in relation to the specialist needs of people living with dementia.

We found that the home was now meeting the requirements of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Assessments were being carried out of people’s capacity to make decisions. Where people lacked the ability to make a decision about living at the home or when restrictions had been placed on them in their best interests we saw that appropriate application had been made for a DoLS assessment. Staff had received training in this area.

Activities and entertainments within the home had improved significantly, with activity coordinators engaging people in activities they found interesting and stimulating. People were having the opportunity to access the garden more frequently as well as more support to go out into the local community.

The home’s environment had improved with new furniture purchased and suitable redecoration and refurbishment being done. The home looked well maintained, homely and welcoming. The garden areas were now a particular feature of the home, with raised flower and herb beds, and these too were well maintained.

We found that the complaints were being better managed. There was now an effective system in place for identifying, receiving, handling and responding appropriately to complaint and concerns.

The service had developed a more robust quality assurance system. Measures had been put in place to improve the running of the service.

Record keeping had improved and staff had received some training on this. However, we did continue to see some recording errors.

The home was now notifying us, CQC, of events they were required to by law.

Overall we found the home was being well-led with the strengthened, more effective management structure that was in place. The north director for FSHC gave assurances of the organisation’s commitment in terms of budget, expertise and continuing support to continue to “put things right.”