Raystra Healthcare improved from Requires Improvement to Good following a focussed inspection of Safe and Well-led domains, having addressed previous regulatory breaches around staff recruitment checks and CQC notifications. The service demonstrated effective risk management, medicines safety, infection control, and strengthened governance and quality assurance systems.
Strengths
· Improvements made to staff recruitment checks following previous breach; robust pre-employment checks now in place.
· Sufficient staffing levels with people receiving visits within allocated time slots.
· Risk assessments and care plans included moving and handling guidance and environmental risk identification.
· Medicines records regularly audited by senior staff and staff described as 'Very thorough' in medicines support.
· Staff had access to PPE, received infection control and food hygiene training, and COVID-19 testing was in place.
Focused inspection found Raystra Healthcare safe but not always well-led, with the well-led rating dropping to Requires Improvement due to ad-hoc, informal quality monitoring processes that failed to identify shortfalls in two people's care plans and risk assessments. Staff practices, safeguarding, recruitment, medicines and infection control were sound, and managers took immediate action to address identified gaps.
Concerns (5)
moderateGovernance: “these processes had not identified the shortfalls identified during this inspection”
moderateGovernance: “Monitoring completed by senior care staff, such as spot checks of staffs' care practices, PPE usage and approach, was not recorded in one central place”
moderateCare planning: “We found two people's care plans and risk assessments did not reflect their current needs.”
minorRecord keeping: “A shortfall in two people's care records, had not been identified through these processes.”
minorCommunication with families: “This process needed to be formalised and feedback from people and their relatives sought as part of the provider's quality monitoring system”
Strengths
· Staff received safeguarding training and knew how to report concerns
· Robust recruitment process including DBS checks and reference verification
· People's consent was sought prior to delivering care and choices were respected
· Staff worked closely with external health and social care professionals to manage complex needs
· Medicines administered by staff who had received relevant training
Quality-Statement breakdown (12)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Ensuring consent to care and treatment in line with law and guidanceNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated