Ayeesha-Raj Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The management team and staff were transparent about previous mistakes made and how they learnt from this. This included reviewing and improving the systems and processes they used to monitor quality and safety. The management team were aware of the importance of continuing to learn and develop the service, whilst sustaining the improvements made. The management team said, “We accept that all levels within the organisation we had become, complacent in some areas. We’ve learnt from this and made improvements.”

Records confirmed how accidents, incidents including any safeguarding events and complaints had been reviewed, investigated and lessons learnt and shared with staff to make improvements. The registered manager said, “We consider any themes, patterns and trends and ensure actions are taken to make improvements. These are discussed with staff via handover, staff meetings and supervisions.”

Staff confirmed learning actions were taken following any type of incident. A staff member said, “We record and report all incidents and report to the local authority and the person’s relative. We have de-brief meetings to discuss any learning and use handovers and staff meetings to also discuss learning.”

Relatives were positive about communication with staff and being informed of incidents, accidents and of action taken to reduce reoccurrence.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they liked living at the service and they felt safe. People knew who the registered manager was and felt confident to raise any concerns. A person said, “I do like living here, I feel safe, and staff look after me well.”

Relatives told us they were confident their family was safely cared for. One relative told us of an historic safeguarding incident and the actions taken by the provider to reduce further risks and confirmed these had been effective with no further incidents.

Staff had received ongoing safeguarding training and had access to the provider’s safeguarding policies and procedures. Staff were knowledgeable about the different types of abuse. They demonstrated an understanding of their role and responsibilities in protecting people from avoidable harm and abuse. A staff member said, “Any concerns we have a duty to record and report to the manager, the local authority and the care quality commission. Someone may report something or a change in a person’s normal behaviour, unexplained bruising could be an indicator something isn’t right.”

The provider had made safeguarding information available in easy read for people using the service and information was also displayed for relatives and visitors. Resident meetings confirmed the agenda included discussions with people about what safeguarding means and gave them the opportunity to raise any concerns.

Records confirmed the local multiagency safeguarding procedure was followed when required. This confirmed staff understood what was expected of them.

A Deprivation of Liberty Safeguard (DoLS) authorisation enables a provider to place a restriction on a person lawfully. Where a DoLS authorisation had been granted with conditions, we saw how these were being met. The provider had systems and processes to monitor DoLS such as expiry dates and conditions and these were working well.

Following our last inspection, improvements had been made to how mental capacity assessments were completed. For example, where a person lacked the mental capacity to consent to a specific decision, the registered manager recorded how and when the assessment was completed. This demonstrated how people were given full opportunity to be involved in decision making. processes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they liked living at the service and they felt safe. People knew who the registered manager was and felt confident to raise any concerns. A person said, “I do like living here, I feel safe, and staff look after me well.”

Relatives told us they were confident their family was safely cared for. One relative told us of an historic safeguarding incident and the actions taken by the provider to reduce further risks and confirmed these had been effective with no further incidents.

Staff had received ongoing safeguarding training and had access to the provider’s safeguarding policies and procedures. Staff were knowledgeable about the different types of abuse. They demonstrated an understanding of their role and responsibilities in protecting people from avoidable harm and abuse. A staff member said, “Any concerns we have a duty to record and report to the manager, the local authority and the care quality commission. Someone may report something or a change in a person’s normal behaviour, unexplained bruising could be an indicator something isn’t right.”

The provider had made safeguarding information available in easy read for people using the service and information was also displayed for relatives and visitors. Resident meetings confirmed the agenda included discussions with people about what safeguarding means and gave them the opportunity to raise any concerns.

Records confirmed the local multiagency safeguarding procedure was followed when required. This confirmed staff understood what was expected of them.

A Deprivation of Liberty Safeguard (DoLS) authorisation enables a provider to place a restriction on a person lawfully. Where a DoLS authorisation had been granted with conditions, we saw how these were being met. The provider had systems and processes to monitor DoLS such as expiry dates and conditions and these were working well.

Following our last inspection, improvements had been made to how mental capacity assessments were completed. For example, where a person lacked the mental capacity to consent to a specific decision, the registered manager recorded how and when the assessment was completed. This demonstrated how people were given full opportunity to be involved in decision making processes.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Relatives confirmed they were involved in discussions and decisions about how risks were managed. A relative said, “I am fully involved in any decision regarding care plans, risks and support.”

Following the last inspection, improvements had been made where required, to staff guidance about how risks were managed. The registered manager told us of a new record they had implemented that provided staff with additional guidance about how a person’s health condition impacted them, including any risks and actions required of staff to provide safe care. We found risks had been assessed and planned for and were regularly reviewed. Guidance for staff about the actions required to mitigate risks was found to be detailed.

The staff had a positive approach to risk taking. An example was given of how a person was supported with a lifestyle choice. Whilst staff respected and supported the person with their choice, they also provided opportunities for the person to consider alternative choices and support.

People were supported by an experienced, stable staff team who knew them well. At this inspection, we identified a person who required staff to support them with their stoma care. This is a delegated healthcare task and requires a district or community nurse to provide staff training and check their competency. Whilst some staff had received specific training from a district nurse, this had been completed many years ago and newer staff had not been trained. Whilst the registered manager had requested additional training, they had not been successful in obtaining this. We asked the registered manager to follow this up again, and training was booked. It was not clear when the person’s stoma was last checked by a healthcare professional, so we asked the registered manager to arrange this, which they did. The person had an associated care plan and risk assessment and these were well detailed. We also saw action taken by staff when concerns had been identified with the stoma area. We therefore concluded the person had received good care and the registered manager was responsive to the actions requested of them.

The provider had a restrictive physical intervention policy and procedure that reflected best practice guidance. Staff received ongoing refresher training. The use of restrictive physical intervention was used as a last resort. The provider had robust systems and processes to assess, review and monitor this practice. Positive behaviour support plans provided staff with up to date and detailed guidance of how to manage and mitigate risks and staff were found to be knowledgeable about these. The provider’s internal positive behavioural lead and the registered manager had good oversight and review procedures were robust.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Following the last inspection, the management team had reviewed and improved their systems and processes that assessed potential risks with regard to the environment, premises and equipment.

The provider’s health and safety monitoring systems and processes were found to be detailed, up to date and effective. New procedures included a formal check of the environment completed by the registered manager. A review of these checks confirmed what actions the registered manager had taken when shortfalls were identified. Following the last inspection, a person’s personal emergency evacuation plan had been reviewed and updated to provide more detailed guidance for staff.

Improvements had been made to the internal environment. This included some re-decoration, including new flooring. The provider had an ongoing refurbishment plan. We observed the environment both internally and externally to be tidy and hazard free.

Relatives reflected on improvements the provider had made at the service over the last 12 months.

Staff told us fire drills were completed regularly. They also explained how staff roles and responsibilities had been reviewed to ensure expectations of staff were clear. These included tasks required of staff in checking the environment remained safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were positive about the staff who supported them. People told us staff provided good care and support and how they understood their individual needs. A person said, “All the staff are brilliant, nothing could be better. They [staff] know me so well.”

Overall, relatives were positive their family member was cared for by competent, experienced and well trained staff. Two relatives gave positive feedback. One relative said, “I am very pleased with the home, and have no complaints at all. I feel staff know [name] needs and requirements in every aspect.” However, a third said, “I am not convinced there are enough trained staff to deal with [name] complex needs and requirements.”

All relatives told us there were enough staff available and their family member received the level of staff care and support they had been assessed as requiring.

The management told us how they determined the staffing levels required, and how this was based on people’s individual needs and was regularly reviewed. Examples were given how staffing increased to support people with appointments and community activities. The staff rota and daily allocation record confirmed staffing levels as described.

Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed.

The provider had systems and processes that supported the staff. Staff received an induction on commencement of their role, ongoing training, and opportunities to discuss their work, training and development needs. These records confirmed compliance with induction, training and supervision and matched the provider’s expectations as per their policies. Training topics were also relevant to people’s individual needs such as learning disability, autism and mental health needs awareness.

Staff were positive about the ongoing training and support they received. A staff member said, “New staff have to complete the care certificate, and HR will inform us when our refresher training is due. I’m happy with the training and would be able to ask for more support if needed. We also get regular supervisions and staff meetings."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Following the last inspection, improvements had been made to infection prevention and control practice. Staff had received refresher training and had improved detailed guidance relating to cleaning requirements. The registered manager had increased oversight and monitoring procedures that were found to be effective.

Our observations found the service to be clean and hygienic. Cleaning schedules were up to date and best practice guidance was being followed. We observed staff to wear personal protective equipment as required. Food hygiene practice was good. The food standards agency rated the service in June 2024 and awarded a rating of 5. This is the highest rating that can be awarded, confirming expected practice was good.

Staff confirmed improvements had been made. A staff member said, “There’s been a lot of improvements made, staff guidance and expectations in relation to cleaning is clearer, making staff more accountable and oversight and checks have improved. The environment looks much better.”

Relatives confirmed they had observed improvements with cleanliness and hygiene. A relative said, “I am happy with the cleanliness."

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Overall, medicines were managed safely. There was a system in place for ordering, storing, returning unused medicines and administering medicines that reflected best practice guidance and relevant legislation. Staff had received ongoing medicines training, including having their competency checked and they had access to the provider’s medicines policy.

However, we found from our review of medicines some minor shortfalls, but there was no evidence of impact on people. For example, medicines were not consistently dated when opened. This included eye drops. This is important to track their shelf life and minimise the risk of contamination and reduced effectiveness after the bottle is opened and exposed to air. We identified one staff missing signature; however, we were able to confirm the medicine had been administered. Staff had not consistently kept or correctly recorded, the stock count of medicines. This was discussed with the registered manager who took immediate actions.

People received their “as and when” (PRN) medicines when they needed it. There was guidance in place for people’s PRN medicine which told staff when this was needed, and how to measure the effectiveness of the medicine. Each person’s medicines records had key information about allergies and how people liked to be given their medicines. The system for managing medicines ensured people were given the right dose at the right time.

We saw examples of how STOMP - [stopping over medication of people with a learning disability and autistic people] principles were being met. For example, regular reviews of peoples’ medicines by the GP or psychiatrist were completed. As a result, some people had a reduction of their antipsychotic medicines.