Riverside House

Riverside House is a care home providing accommodation and personal care for up to 46 older people, including those living with dementia. At the time of the assessment there were 37 people living at the home.

We identified that the home did not have the service user band for older people recorded in its details with the Care Quality Commission (CQC). Service user bands are categories used by CQC to describe the types of people a service supports. They help to ensure providers only deliver care to people they are approved for, based on their skills, resources, and environment. The new manager told us this would be addressed as part of an update to their Statement of Purpose and service user bands.

We carried out this inspection because concerns had been raised about the quality of people’s care, some of which were submitted anonymously. These concerns included issues relating to people’s safety and the management of the home.

During the assessment we identified shortfalls around people’s safety, the effectiveness of care, and the overall management of the home. We found the provider was in breach of the legal regulations relating to safe care and treatment and good governance.

The home had experienced a period of significant change during 2025, including several changes in management. These changes together with other challenges, had led to staff complaints, increased absences and departures. This had affected morale and stability within the home, resulting in inconsistency in care delivery and oversight.

Systems to keep people safe had not been fully effective. We found shortfalls with medicines management, nutrition, risks relating to 1 person’s fluids, falls management and catheter care.Governance systems had also been ineffective in monitoring quality and safety whichmeant risks were not consistently identified or addressed in a timely manner.

At the start of our assessment, the home was managed by a national care home management company. The nominated individual told us they had decided to move to a self-managed model to enable closer involvement in operations and drive improvements beyond what was possible under an external arrangement. By our second site visit, the management company was no longer involved.

On our third visit to the home, a new manager was in place who had been in post for a week. She had begun addressing the shortfalls identified both before and during our assessment. These actions were positive, but the new processes still needed to be fully embedded into day‑to‑day practice to ensure consistency and sustainability.

Despite the shortfalls, we identified areas of good practice. Safe recruitment practices were followed, reducing the risk of unsuitable staff being employed. Infection prevention and control arrangements were effective. Staff promoted people’s independence, choice and control in day to day decisions, and activities and support were adapted to meet people’s needs, which helped contribute to equitable experiences and outcomes. Further examples of how the home provided compassionate, person centred and responsive care are detailed within the people’s experience commentary below.