CQC report explained · a residential care home
What the CQC found at Ayeesha-Raj Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2019
Ayeesha-Raj Care Home was rated Requires Improvement; inspectors found kind staff and detailed risk plans, but weak oversight and gaps in care, cleanliness and activities.
This was an unannounced inspection on 23 May 2019. One inspector and an expert by experience spoke with two relatives and six staff. They reviewed three care plans, medicines records and the home’s quality checks.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found staff were calm and caring, risks were assessed, medicines records were generally complete and people could access health professionals.
There were also important shortfalls. Some areas were not clean, some as-needed medicines lacked guidance, meals and communication support were not always suitable, activities were limited, care plan reviews were weak and management checks had not found these problems.
The home had previously been rated Good in November 2016. The provider breached Regulation 17 on good governance. CQC asked for an action plan and said it would continue monitoring the home and return to inspect.
Kind and familiar staff
Inspectors saw staff behaving calmly and kindly. Staff knew people well, and relatives described them as kind and caring.
“Staff were calm, kind and caring and we observed that they knew people well.” from the report
Risk management
Care plans included detailed risk assessments. Staff understood the risks and the actions needed to reduce them, including risks linked to behaviour.
“Risk assessments were detailed and were reviewed and updated swiftly if there had been any changes or incidents.” from the report
Staff training and support
Staff had induction training, ongoing training and regular one-to-one support. Recruitment checks were completed before new staff started.
“The system for staff supervision and support was consistently applied.” from the report
Health care links
The home worked with health professionals and supported people to attend health checks and appointments, including with opticians, dentists and chiropodists.
“Staff worked with other health and social care professionals to achieve good outcomes for people's health and wellbeing.” from the report
Weak management checks
seriousQuality checks had not identified problems with medicines guidance, cleanliness, care plan reviews or communication support. This led to a breach of Regulation 17.
“There had been a lack of consistent managerial oversight of systems in place to develop the service further and ensure continuous improvement.” from the report
Cleanliness and condition
needs fixingInspectors found stained carpets, dirty toilets, dust and stains, dirty handrails and missing liquid soap. The premises also needed refurbishment, redecoration and a deep clean.
“Although the service was clean in most areas we found some areas that were not clean and safe from the risk of infection.” from the report
Food and mealtime support
needs fixingInspectors did not see fruit or vegetables offered at lunch. One staff member could not identify a person’s meal, and another supported someone to eat without explaining the food.
“On the day of our visit we did not observe people receiving a nutritious, balanced diet.” from the report
Communication and choice
needs fixingMenus, complaints information, care plans and safeguarding information were not available in enough accessible formats. Inspectors could not be confident that people understood the food choices offered.
“People's communication needs, although identified had not been met, for example, there was a lack of information in different formats to meet their communication needs.” from the report
Care plans and activities
needs fixingCare plans contained outdated information and reviews often only said there were no changes. Inspectors saw few activities, and comments about limited activities had not led to action.
“There was no evidence that these concerns had been acted upon.” from the report
Management continuity
needs fixingThere was no registered manager at the inspection. Staff and a relative reported several management changes, which affected confidence in consistent leadership.
“Staff told us there had been numerous different managers, but they didn't stay in post for long.” from the report
- 01What has been done to make sure all areas are clean and safe from infection risks, and how is this checked now?
- 02Do all as-needed medicines now have clear written guidance, and are staff competency checks recorded?
- 03How are people given accessible menus and other information so they can understand choices and make decisions?
- 04How are care plans reviewed to remove outdated information and make sure daily care matches the plan?
- 05What activities and outings are now available, and how have people’s comments about limited socialising been used?
This was an unannounced planned inspection covering the overall service and all five key questions, including the premises and care provided. This explanation was written from the published report of 26 June 2019 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.
What inspectors found, November 2016
Ayeesha-Raj Care Home was rated Good overall; inspectors found safe, kind and personalised care, but improvements were needed in mental capacity checks.
Inspectors visited without warning on 4 October 2016. They spoke with seven people living in the home, the manager and five care workers. They reviewed three care records, medicines records, staff files, training records, rotas and quality checks.
People told inspectors they felt safe. Staff understood safeguarding, risks were assessed and medicines were managed safely. Staff were kind and respectful, supported people's choices and helped them stay independent. Care plans were detailed and people were involved in reviewing them.
The main weakness was that the home was not consistently following the Mental Capacity Act. Some required Deprivation of Liberty Safeguards applications had not been made at the time of the inspection. The manager had identified this and began taking action.
The overall rating of Good means inspectors found the service met the expected standard overall. However, the Effective rating was Requires Improvement, so the home needed to complete and maintain its work on mental capacity and related legal safeguards.
People felt safe
People said they felt safe, and staff understood how to recognise and report abuse. Recruitment checks had been completed before staff started work.
“People were protected from harm and staff were clear of their role to keep people safe and protect them from abuse.” from the report
Kind and respectful care
Inspectors observed staff treating people with kindness and compassion. People's privacy, dignity, choices and personal belongings were respected.
“Throughout our inspection visit we saw that people were treated with kindness and compassion by the staff members who were supporting them.” from the report
Personalised support
Care plans included people's preferences, routines, interests and life history. People were involved in reviewing their care and setting personal goals.
“We saw that the level of detail in the care plans was sufficient so that staff had all the information they needed to provide care as people wished.” from the report
Strong management checks
The manager and area manager used audits, staff meetings and an action plan to identify and address improvements. People were also involved in developing the service.
“This demonstrated that the provider had a system in place in order to ensure sustainable improvement.” from the report
Mental capacity safeguards
needs fixingThe home was not consistently following the Mental Capacity Act. Some DoLS applications had not been made when required, although the manager had started corrective action.
“We found that the service was not consistently doing so.” from the report
Community access risk
needs fixingOne person's risks when accessing the community had not been formally assessed. The manager agreed to review this with the person.
“We identified that the risks associated with accessing the community for one person had not been formally assessed.” from the report
Activities and staffing
needs fixingSome people said staffing levels sometimes stopped them going out. Inspectors also saw periods when people were not engaged in activities, and staff said more activities could be offered.
“Not always enough. Short staff stops me from going out.” from the report
- 01What action was completed to ensure all required Deprivation of Liberty Safeguards applications are made promptly?
- 02How do you now assess and record whether each person can consent to personal care, medicines and other decisions?
- 03How are risks for people accessing the community assessed, reviewed and discussed with them?
- 04How do staffing levels ensure people can take part in their chosen community activities?
- 05What new or improved activities are now available for people who spend time watching television or people-watching?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the service. This explanation was written from the published report of 8 November 2016 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.
Every inspection of Ayeesha-Raj Care Home
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- June 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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