Ayeesha-Raj Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Staff felt supported by the registered manager. People’s views about the service were sought and listened to. At the last inspection (published 26 June 2019) the provider was in breach of regulation in relation to good governance due to ineffective systems to monitor the quality of the service. At this assessment not enough improvement had been made and the provider remained in breach of regulation. Systems to assess and monitor the quality and safety of the service were in place but were not effective in identifying the concerns found during this assessment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders were passionate about delivering effective care to people, and described the service as being like a family. The culture felt open, although staff had limited experience of care outside of the service.

Systems and processes were in place to ensure the service was run openly. Contingency and continuity plans were in place at the service and the provider was aware of issues that may impact the opportunities of people living at the service and provided training.

Staff told us leaders at the service were skilled and knowledgeable. Staff felt very supported by management and felt the registered manager and leaders were compassionate and visible.

Policies were in place to guide staff on expected behaviour and visions, and also provided the registered manager with information on how to ensure staff met needs of people. Feedback opportunities were available for people, relatives and staff to raise concerns and make improvements.

Staff felt able to speak up and that management would take action as required. Staff knew there were external agencies such as the local authority and CQC who could be contacted if they had any concerns. People and relatives also felt able to raise any worries or concerns.

Systems and policies were in place for staff to speak up and/or whistleblow if required.

Each new recent starter had completed a comprehensive training and induction document which was completed over a number of weeks. The registered manager advised the induction completions were reviewed and staff felt included and valued by each other and the management team.

Processes were in place to ensure staff groups' diverse needs were identified and utilised. Positive feedback around staffing and management was received.

Supervisions and team meetings regularly occurred at the service. Frequency of events appear to be sufficient and staff feel the information available to them and the opportunity to learn enables them to develop and undertake their roles. Despite processes and systems being in place to support the governance of the service, they were not sufficient to ensure concerns identified during assessment were identified independently.

Systems and processes were in place to manage the service, but they were not always effectively used. There was a repeat breach of good governance regulation and a new breach in relation to safe care and treatment identified during this assessment. The registered manager and provider had not been able to sustain changes required at the service despite having the skills and knowledge to do so.

People were supported well by staff who collaborated with and shared information with relevant partner agencies.

The registered manager told us they had a positive working relationships with a wide variety of health and social agencies and collaborated with them to ensure people received quality care.

Evidence showed the provider worked well with a number of partner agencies to achieve the best result and outcomes for people using the service.

Staff maintained accurate records of the care people received. This information enabled healthcare professionals to assess and review people’s needs and recommend any changes needed to the care people received.

Staff and the registered manager were positive about learning lessons and reviewing any incidents that occurred. For example, following incidents. One staff member told us, "If there has been an incident we do recaps and training based on the incident. We update training and look at how we can learn together We also have team leader meetings too where we can make decisions and listen to what we think we can change." However, lessons had not been learned around the governance at the service since our last inspection and concerns remained.

The registered manager and provider were positive about learning lessons and were receptive to any areas identified as requiring improvement during the assessment. Processes to make improvements and learn lessons were not always effective as concerns identified at the last inspection 5 years ago were present again at this assessment.