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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The staff team knew and understood the provider’s vision, values and purpose. The provider’s aims and objectives were displayed within the service and discussed with staff in supervision and staff meetings. A staff member said, “Our aim is to provide the best quality of care we can, meeting expected standards of care and ensuring people are happy, safe and well cared for.”

The registered manager told us how they promoted equality and diversity within the staff team. The registered manager said, “We ensure equal opportunities for all staff, we support staff to raise any concerns by creating a safe place, we encourage staff to raise any adjustments required and review and support these.”

People were involved as fully as possible, in discussions and decisions about their care and support needs, including how they spent their time and were supported with activities and routines important to them. For example, people met monthly with their link worker, a named staff member who had additional responsibility in ensuring people’s individual needs were met. This included discussion about activities people had participated in within the month and plans were made for the following month. People also had the opportunity to attend resident meetings where important information was shared about the service, including people being consulted about meal options and activities.

The provider had an inclusive approach where relatives and friends could visit the service at any time. Relatives received opportunities to share their experience of the service, to raise any issues or concerns and were invited to meetings and events held throughout the year. A relative confirmed this and said, “There are no issues with visiting as the home operates an ‘open house’ policy.” Another relative said, “The home holds events for parents such as BBQ’s in the Summertime and a Christmas party which I always attend."

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager and director of the service had worked at the service for many years. This brought consistency and continuity. From our observations of both the registered manager and director engaging with people who used the service, they appeared to know people’s individual needs, routines and what was important to them very well. The management team also appeared to have a good relationship with the staff team, where they were observed to be approachable and supportive.

Following the last inspection, the management team had reflected how and why, the service had not met the fundamental care standards expected of all registered health and social care services. Since the last inspection, they had reviewed and improved their systems and processes, including ensuring all staff were fully aware of their roles, responsibilities and accountability. Staff confirmed expectations and clarity of roles and responsibilities had improved. Staff spoke highly of the management and leadership of the service and how well the staff team worked together. A staff member said, “Colleagues are all hardworking and do a good job we work well as a team."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager told us how they supported staff to feel able and confident, and to raise any issues or concerns. The registered manager said, “I'm open in saying to staff we can't improve if we don’t know. I encourage them to share any concerns, but also to go above me if necessary to outside agencies. We have a duty of care and responsibility to keep people safe. I don’t react negatively when concerns are raised, I make sure any issues brought to my attention are positively responded to and provide feedback of my actions.”

Staff confirmed they knew and understood how to raise any issues or concerns. They had access to the provider’s policies and had regular contact with the director who they could approach. A staff member said, “The registered manager is very pleasant and a good manager, they have an open door policy, and you can take anything through to them, they are always readily available, they listen and respond to staff.”

The provider had relevant policies to support the staff such as whistleblowing and freedom to speak up procedures and these were available for staff.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff were valued for their contribution, and an inclusive, equitable culture had been developed. Staff came from a variety of ethnic backgrounds with different cultural and religious beliefs. Adjustments were made to the rota to enable staff to take holidays at times that were significant for them.

Staff received opportunities to share their experience of working at the service via annual staff survey. We reviewed feedback received in 2024 and found this to be positive. Staff were aware of, and understood, the provider’s policies on whistleblowing and equality and diversity.

Staff confirmed they were treated equally and fairly. A staff member said, “The provider / owner of the business visits regularly and I feel comfortable to speak with them. The director is friendly and approachable, and I feel I can raise any concerns in confidence. The registered manager is very approachable and supportive too, she ensures that we work as a team, she has an open door policy and treats staff fairly and equally."

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

New and improved systems and processes that assessed, reviewed and monitored quality and safety had been improved upon since the last inspection. A review of audits and checks confirmed new and improved ways of working, had been embedded and improvements were being sustained. An ongoing action plan was supporting the management team to continually drive further improvements. The management and staff team showed a commitment and determination to ensure the service maintained consistent good standards.

People’s care plans and records were reviewed regularly and involved the person as fully as possible and the person’s relative, and others such as external health and social care professionals. The registered manager said, “Care plan reviews are needs led, at a minimum they are bi-monthly. We currently have weekly, monthly bi- monthly reviews required."

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People and relatives were positive about the service provided. People were supported to access external health and social care support and services and were active citizens of their local community.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff worked with a range of external health and social care professionals. People’s care records confirmed staff made timely referrals to external professionals for further assessments and guidance. Recommendations made were seen to be recorded and implemented.

The service was located in the centre of a busy community with a variety of facilities that people accessed frequently.

The provider focused on continuous learning, innovation and improvement across the organisation and local systems. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service was managed by a stable and experienced management team. Since the last inspection, improvements had been made and previous breaches in regulation met. The provider had reflected on how things had gone wrong and had learnt from this. Whilst new and improved systems and processes had been developed, the provider had an ongoing action plan to drive further improvements.

The registered manager told us of external support and resources they accessed, such as local authority provider forums, local networks and Skills for Care - a strategic workforce development and planning body for adult social care in England.

Staff received ongoing training and support, including encouragement to progress their training through national vocational training.