Archived: Radis Community Care (Brunel Court)

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 inadequate. At this assessment the rating has changed to requires improvement.
This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safeguarding service users from abuse and improper treatment and staffing. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.
The provider was previously in breach of the legal regulation in relation to safe care and treatment and fit and proper persons employed. Improvements were not found at this assessment, and the provider remained in breach of these two regulations.
 

This service scored 50 (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 worked to develop a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

The manager could describe some improvements that had been made following incidents. However, actions and outcomes in response to incidents were not always recorded, and lessons were not always learnt to continually identify and embed good practice.

People and staff felt they could raise issues, and senior staff would address their concerns. The manager had oversight of incidents, accidents and complaints but it was not always clear from the incident records what action had been taken or the outcome for the person involved. A record is important to show proper oversight and ensure improved outcomes are added to people’s care plans for staff to follow. However, detail in the incident reports had improved since the current manager started managing the service in July 2025. Incident analysis was undertaken in relation to individual people. However, incidents had not always resulted in analysis across the service therefore opportunities had been missed to identify and improve safety from themes and trends across multiple people. The manager was working towards improving these areas following the inspection, but this still needed to be embedded within the service.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider used the initial assessment from the commissioning body or hospital to determine the person’s needs. They then assessed people when the person came home to start the package of care for any changes. The provider ensured care was organised flexibly, with adjustments made to meet people’s changing needs. This included when people’s health needs changed or when they were admitted to or discharged from hospital. There was evidence of increases in care calls to meet changes in needs. Staff told us they were always informed when people started with the service, or people came out of hospital with different needs. Information was available to staff via the handover book.
 

Improvements had been made following our previous inspection. Safeguarding concerns had been identified and the provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

The manager demonstrated a thorough approach to investigating safeguarding concerns, to help reduce the risk of people suffering abuse or coming to avoidable harm. Safeguarding incidents were referred to the local authority where appropriate. However, CQC had not always been notified of abuse concerns which had been found to be unsubstantiated following investigations. The provider had policies and procedures in place for safeguarding. However, this did not include contact details such as the local authority safeguarding team to enable staff to raise safeguarding alerts if the provider had not done so. People and relatives told us they felt safe receiving support from the staff. Staff we spoke with felt able to raise safety concerns and said they would be dealt with properly. Staff were trained in safeguarding and knew how to recognise the signs of abuse and the appropriate action to take.
 

Although the provider aimed to work with people to understand and manage risks, we found ongoing concerns with actions to reduce risks to people not always fully considered and clearly documented. Staff did not always have the information needed to provide care that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in place, but not all potential risks had been considered. There was not always a risk assessment for flammable emollients and the control measures staff and people needed to take to reduce the risk of fire. Where people were at risk of choking, they did not always have a suitable risk assessment in place to guide staff to keep people safe when they were choking. This could have serious outcomes for people. People’s care plans had not been updated or reviewed following falls. Although the manager was able to describe some actions taken in relation to falls, care plans were not accurate and reflective of these. Staff told us falls information was not always in people’s care plans. The manager worked to resolve this during the inspection.

The provider assessed people when they arrived in the service to understand their needs and associated risks. However, staff told us they did not always have all the information they needed when people first started or returned to the service. The manager told us this was because the assessment had not yet updated the care plan, and they would look to improve this.
Where risks had been identified, associated monitoring charts such as for bowels, skin integrity, repositioning, and food and fluids were not in place to ensure systematic monitoring of people’s risk so that concerns would always be escalated when needed. This placed people at risk of poor care due to lack of effective oversight to keep people safe. The manager looked at ways to improve this during the assessment by using their electronic care system.
 

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

The provider carried out assessments of people’s home environments to identify and reduce any risks related to the delivery of care. This included checking when hoists were last serviced and arranging for hoists to be inspected to make sure they were safe to use. Staff we spoke with told us it was important to check the environment was safe on every call, being aware of what to look out for. The provider used technological solutions to aid the delivery of safe care, with staff using devices to access care information about people. This helped to improve safety and the provider’s ability to monitor how care was delivered.
 

Improvements had been made following our previous inspection and the provider made sure there were enough qualified, skilled and experienced staff to meet people’s needs.
However, we identified ongoing concerns in relation to recruitment, and the provider had failed to ensure staff were recruited safely. A suitable recruitment policy was in place, but internal guidance did not follow this, limiting the provider’s ability to meet the regulations. We found shortfalls in recruitment processes for all 3 staff files we reviewed. Not all the required information was available at the time of the inspection. This included full work history, evidence of Disclosure and Barring Service (DBS) checks and evidence of conduct in previous roles in health or social care, or with children or vulnerable adults. There was a risk unsuitable staff might therefore be recruited.

Mandatory training was in place and monitored for completion. However, staff told us they could benefit from regular knowledge updates in relation to people’s specific health conditions. Staff also told us more face-to-face training would be beneficial. Extra information was available to staff on certain health conditions put together by the manager to aid staff’s understanding.
Staff competency and spot checks were completed more frequently since the current manager started managing the service in July 2025. The quality and detail of these were good with evidence of follow up discussions with staff where needed to develop their practice and skills.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Some people and relatives we spoke with were concerned staff were not wearing aprons or disposing of gloves appropriately. This included not wearing an apron when emptying a catheter bag, and washing soiled gloves in a washing up bowl before disposing of them. This increased the risk of cross infection. However, the manager had increased the frequency and quality of spot checks to help identify any poor practice to improve in this area. A suitable infection prevention and control (IPC) policy was in place as well as staff training.
 

We found ongoing shortfalls in relation to medicine management. The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. However, staff did involve people in planning and administering their medicines.

Some people had missed their medicines prior to our inspection. In response the provider had put in place wellbeing checks from their first responder to check if medicines had been administered as prescribed. However, these checks were not completed throughout the whole day and therefore opportunities could be missed to identify medicine errors. This meant people were at risk of not receiving their medicines as prescribed.
There was a suitable medicines policy in place covering the need to call 111 or a pharmacy to check for harm if medicine was not taken. However, the provider’s internal guidance only required staff to take this immediate action for a list of critical medicines. There was no evidence of how this list was kept up to date or who agreed on the content. Medication administration records (MAR) were audited weekly for a sample with all MAR checked monthly. This meant missed medicines not on the provider’s critical list would not be followed up in a timely manner to determine the impact on people or if any remedial action was required. This included any missed prescribed creams.
It was not always clear to staff in people’s care plans who was responsible for re-ordering and receiving medicines. This meant people could be at risk of running out of stock and missing their medicines. The manager said they would review this to make sure it was clear.

The provider’s electronic system enabled updates to medicines to be made as soon as changes were known. This meant staff had up to date information available on people’s medicines.
The manager had put together fact sheets for medicines for certain conditions (such as Parkinson’s disease) in people’s flats to aid staff’s understanding of the prescribed medicine.
Staff were trained in medicines administration and their competency checked more frequently since the new manager started in July 2025. As required medicines (PRN) had appropriate protocols in place to guide staff when people needed them.