Ayeesha-Raj Care Home

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

The inspection was undertaken to follow up on enforcement actions following the previous inspection in May 2024. At the last inspection, the provider was required to make improvements to infection prevention and control practice, and governance procedures that monitored the quality and safety of the service.

At this inspection, we found improvements had been made and new and improved systems, processes and procedures had been embedded and sustained. The service was no longer in breach of any regulations. We reviewed the quality statements in relation to Safe and Well-led Key Questions only.

People received safe care and support. Improvements had been made to infection prevention and control practice. The service was found to be clean and hygienic. Increased monitoring and updated guidance for staff of expected actions were found to be effective.

The environment had been improved upon. Some redecorations had been completed, including new flooring. An ongoing refurbishment plan was in place to make further improvements. The systems and processes that assessed and monitored the environment had been improved upon, with increased oversight and these were working well.

People’s care plans and risk assessment guidance for staff on how to safely meet individual needs had been improved upon. Where guidance needed to be more detailed, we found this had been completed. There was a positive approach to risk management. External professionals, the person as fully as possible, and their relative, were involved in discussions and decisions about how risks were managed and mitigated.

People were supported to keep safe. Staff were aware of their role and responsibilities to support people from avoidable harm and abuse. People were supported by an established, experienced staff team who knew them well. The provider had safe staff recruitment procedures. There were enough staff available to meet people’s care needs and where people had been assessed as requiring additional staff support, this was being provided.

The provider had a positive learning culture. The registered manager, provider and staff team had reflected on the outcome of the last inspection and what had gone wrong. They had learnt from previous mistakes and had made improvements. Accidents and incidents were reviewed for lessons learnt and discussed with the staff team to reduce reoccurrence.

People received continuity of care. Procedures were in place to support people effectively and share information with others when moving to the service or being discharged to an alternative placement. The staff team worked well with external professionals.

The provider’s systems and processes that assessed, reviewed and monitored quality and risks had been improved upon. Oversight of the service by the provider had increased. An ongoing action plan supported the service to further drive improvements.

Staff were positive about working for the provider. They felt well supported by the management team. Internal communication systems and processes were found to be effective. Staff had access to the provider’s policies and felt able to raise any issues or concerns.