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CQC report explained · a residential care home, run by Mrs C Day and Mr & Mrs S Jenkins

Riverside Court

Bridge Street, Boroughbridge, York, YO51 9LA

Requires improvementpublished 6 March 2025, 17 months ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The latest report, explained

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.

What inspectors praised
  • 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 livesfrom the report
What inspectors were concerned about
  • Unmanaged safety risks

    serious

    Important 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

    serious

    Some 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

    serious

    Concerns 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

    serious

    Staff 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

    serious

    There 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
Questions to ask them, based on this report
  1. 01What evidence can you show that individual risks, including falls, self-harm, access to stairs and skin damage, are now assessed and reviewed?
  2. 02How are medicines now stored, administered and recorded, including creams, controlled drugs and 'when required' medicines?
  3. 03What staffing levels are planned for each shift, especially at night, and how will absences be covered?
  4. 04What has been done to complete the fire safety actions, update safety checks and secure access to the building?
  5. 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.

The story over the years

Every inspection of Riverside Court

7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.

  1. November 2023Inadequatecurrent ratingdown from Good
    Safe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate

    Read what inspectors found at Riverside Court

  2. January 2021Goodstayed Good
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. August 2018Goodup from Requires improvement
    Safe: GoodEffective: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. June 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  5. June 2016Requires improvementup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. January 2016Inadequatedown from Requires improvement
    Safe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  7. July 2015Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  8. June 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. May 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. August 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. May 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. March 2011

    Registered with the Care Quality Commission on 16 March 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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