About the service:

Raj Nursing Home is a care home that is registered to provide personal and nursing care for up to 28 older people, some of whom are living with dementia. At the time of the inspection 24 people were using the service.

People’s experience of using this service:

At our last inspection we found a breach of the regulations relating to safe care and treatment. This was because some aspects of the environment were not kept in a safe manner. At this inspection we found safety in those areas that previously had been a cause for concern had been improved. During this inspection we still found some areas that might pose a risk to people, that had not been identified or addressed by the provider.

During our inspection people told us they received their medicines in a timely manner. Whilst medicines administration records were completed by the nursing staff appropriately, some information had not been updated to reflect people’s current medicines regimes.

At this inspection we also found that care plans were not person centred because they did not contain background information relevant to the person and did not always contain what support people required with their diverse needs. Care plans did not state what activities people might enjoy and we found a lack of meaningful activities in the service.

There had been no registered manager in post since August 2018 and there had been several changes in manager since our last inspection. The current manager had applied to register with the CQC. The provider ensured they were present in the service to support the manager to make identified changes, but difficulties recruiting staff, in particular nursing staff had impeded this process. Therefore, whilst the provider had undertaken checks and audits and had in place a comprehensive action plan there was a delay in making some planned changes to the service provision.

The manager had assessed staffing needs in the home and put in place additional staff if someone had a higher support need. Notwithstanding this, most people and relatives told us staff were often very busy and said there was sometimes a delay in call bells being answered at key times in the service.

At our last inspection we found a breach of the regulations about the need for consent. At this inspection we found this had been addressed and care plans we reviewed were signed by the person or their legal representative to show they had agreed with their care plan. We saw also that the manager had applied for Deprivation of Liberty Safeguards on behalf of people who were assessed as not having capacity to consent to their care and treatment.

People described staff as caring and friendly and said despite them being busy they made time to talk with them. We saw staff were respectful towards people and asked their permission before supporting them. People said staff maintained their privacy and dignity.

People told us they liked the meals provided and there was a picture menu to choose from and alternative meals were offered. People with dietary needs were supported and staff encouraged all people to have enough to drink. The provider ensured people had access to health and social care professionals to maintain their well-being.

Rating at last inspection: At the last inspection on 10 May 2018 we undertook a focused inspection for the key questions safe, effective and well-led and rated these requires improvement and therefore the overall the rating was requires improvement.

Why we inspected: We brought the inspection forward because a Healthwatch visit on 8 January 2019 had identified concerns about staffing levels and support for them, the lack of a menu and activities for people on the day of their visit.

Improvement action we have told the provider to take: Please see the actions we have told the provider to take section towards the end of the report.

Follow up: We will ask for an action plan from the provider to address the areas wher

This unannounced inspection took place on the 20 March 2018. At the last inspection on 24 July 2017 the service was rated ‘Good’ in all key questions and overall.

For this inspection the team inspected the service against three of the five questions we ask about services: ‘Is the service safe?’, ‘Is the service effective?’ and ‘Is the service well led?’ No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection. During this inspection, we rated the service ‘Requires improvement’ in each key question inspected and overall.

Raj Nursing Home is a ‘care home’ with nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates up to 28 people in one adapted building consisting of two floors. They offer a nursing care service to older people, some of whom may be living with dementia. At the time of our inspection there were 20 people living at the home.

There was no registered manager in post as they had left employment at the home and deregistered prior to our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was in the process of recruiting for a manager.

The provider had not adequately assessed the risks to people using the service. The areas of concern included stairs access not being assessed, a tripping hazard not removed, uncovered radiators and unlocked boiler and electric cupboards and sluice room. There was also a lack of review around some manual handling risk assessments to accurately describe the equipment needed to move people or when people’s needs had changed.

People in their bedrooms did not always have access to their call bell and were therefore unable to call for staff support should they need to do so.

We found that infection prevention and control procedures were not always followed robustly by staff to help prevent the spread of infection.

We found a few concerns around medicines management which could put people at risk of not receiving their medicines safely. These concerns had not been picked up by the various checks in the home so they could be addressed.

The provider was not always working according to code of practice of the Mental Capacity Act 2005. This was because we found that relatives signed consent forms when it was not confirmed they had a lasting power of attorney, giving them the right to make decisions on their family member’s behalf. In addition, when applications under the Deprivation of Liberty Safeguards had been authorised, the provider had not requested for a re-assessment in a timely manner where these authorisations have expired.

The service was not always well-led as although the management team carried out audits and checks, the above concerns were not identified so the necessary improvements could be made. We also found that records were not always being maintained accurately and stored safely.

We found three breaches of Regulations. These were in relation to safe care and treatment, need for consent and good governance. You can see what action we have asked the provider to take at the back of the report.

Relatives were encouraged to visit the home to see their family members. They had not been kept up to date with developments in the home and the management team agreed to address this by ar

This inspection took place on 24 July 2017 and was unannounced. At the last inspection on 11 and 12 March 2015 we found the service was rated ‘Good’ in all key questions and overall. At this inspection, we found the service remained rated ‘Good’ overall.

Raj Nursing Home is a care home, which provides accommodation, nursing and personal care for up to twenty eight adults, some of whom have dementia. The home accommodates people from different cultural backgrounds. At the time of the inspection the majority of people living at the service were from an Asian background. There were twenty three people using the service at the time of our visit. The accommodation is laid out over two floors. The first floor can be accessed by a lift. Each person had their own bedroom and could access the communal facilities such as a lounge, dining area and garden.

There was a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had systems in place to keep people safe. There were policies and procedures guiding staff on how to protect people from harm and abuse. Staff we spoke with knew what to do if they thought somebody was at risk of harm. Risks to people’s health and wellbeing were assessed and staff had guidelines telling them how to minimise and managed these risks. People received their medicines as prescribed and staff were appropriately trained to support people with taking of their medicines.

The provider had effective staff recruitment procedures to ensure that staff were safe to work with the people using the service. There were sufficient numbers of staff deployed to support people safely and effectively.

People were supported by staff who received appropriate induction to their role and duties and were sufficiently trained and skilled. Staff received regular support and supervisions from the registered manager to ensure that they provided the care that was safe and responsive to people’s needs and preferences.

The CQC monitors the operation of the DoLS (Deprivation of Liberty Safeguards) which applies to care homes and hospitals. The registered manager had submitted applications under DoLS where people might have been deprived of their liberty and they followed up on these applications to check if these had been authorised. Staff were knowledgeable about the Mental Capacity Act 2005 (MCA) and decisions about people’s care were made in their best interests.

Staff supported people to maintain good physical and mental health and have a balanced and nutritious diet that reflected people’s health needs and personal preferences. Staff had made appropriate referrals to relevant healthcare professionals to ensure changes in people’s care and health needs were addressed in a timely manner.

People told us they liked staff who supported them and they were happy with the care provided. We saw that staff were gentle and kind when caring for people and had taken the time to support people and make them feel they mattered. Staff respected and maintained people’s right to dignity and privacy and they managed end of life care with sensitivity and compassion.

Each person using the service had an individual care plan that was personalised and contained specific information on their care needs and preferences. People had access to activities in the home and were supported in maintaining relationships with friends and family members.

People and their relatives were asked about their opinions on how the service was managed and provided. The registered manager responded to any suggestions and complaints appropriately and in a timely manner.

Staff told us they felt supported by the regist

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practicing professional.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

People who use the service told us that staff were kind and respected their privacy and promoted their independence. People told us staff understood their needs and provided them with the care and support they needed in the way that they wanted. They told us their religious and cultural needs were met by the home, and staff spoke with them in the language that they understood. Two relatives told us “it is like family here”.

People told us the food was “nice” and their choices were respected. They also told us they felt safe and they could speak to staff if they had any concerns.

People who use the service told us that they were happy with the staff. Comments

made by people using the service included "I am happy with the service" or "service

very good".

This inspection took place on 11 and 12 March 2015 and was unannounced. At the last inspection on 13 and 15 November 2013 we found the service was meeting the regulations we looked at. Raj Nursing Home is a care home which provides accommodation nursing and personal care for up to twenty eight adults, some of whom have dementia. The home accommodates people from different cultural backgrounds. At the time of the inspection the majority of people living at the service were from an Asian background. There were twenty one people using the service at the time of our visit.

The accommodation is laid out over two floors. The first floor can be accessed by a lift. Each person had their own bedroom and can access the communal facilities such as a lounge, dining area and garden.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe. Staff knew how to protect people if they suspected they were at risk of abuse or harm. Risks to people were assessed and management plans to minimise the risk of harm or injury were in place.

Safe recruitment practices were followed and sufficient staff were recruited to help support and keep people safe.

Arrangements were in place to ensure medicines were appropriately managed, so that people received the medicine they were prescribed.

People received care and support from staff that had the required skills, knowledge and training to meet their needs effectively. Staff support was provided through a programme of supervision and appraisal.

CQC is required by law to monitor the implementation of the Mental Capacity Act (MCA) 2005 and the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS provides a process to make sure that people are only deprived of their liberty in a safe and least restrictive way, when it is in their best interests and there is no other way to look after them. The service met the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Where people did not have the capacity to consent to specific decisions the staff involved relatives and other professionals to ensure that decisions were made in the best interest of the person and their rights were respected.

People received individualised support that met their needs. People told us they were involved in the development and review of their care. Care was planned and delivered in ways that enhanced people’s safety and welfare according to their individual needs and preferences.

People’s nutritional needs were assessed and they were supported to eat and drink food that met their preferences. Staff supported people to attend healthcare appointments and liaised with their GP and other healthcare professionals as required to meet people’s needs.

Relatives spoke positively about the staff and their kindness and compassion for the people they supported. People’s privacy and dignity were respected. Staff were caring and knowledgeable about the people they supported.

The service was well led by an experienced and approachable manager. The culture within the service was positive, open and inclusive.

Systems were in place to assess and monitor the quality of the service. People and their relatives felt confident to express any concerns or issues they had with the manager, so these could be addressed.