Archived: Radis Community Care (Brunel Court)

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• 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 inadequate. At this assessment the rating has changed to requires improvement.
This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.
 

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.
However, although they understood the challenges and the needs of people; the care people received did not always reflect the service’s values and objectives as set out in their statement of purpose. People did not receive care that was always high-quality care or person centred.

Staff reported issues with the attitude of some of the care staff, telling us it wasn’t very nice to work there at times. However, there had been improvements with the appointment of the new manager. One staff member told us, “At first not as easy but it is getting a lot better now. [The] manager is doing well and getting a good relationship with everyone.” Staff were also appreciative of the support given by the team leaders, and they were good examples to other staff. Staff said they did not always have all the information they needed, and it would be better once all the risk assessments were available on their devices. Improvements in the culture of the service were being made but these needed to be imbedded to ensure high-quality, person-centred care was consistently being delivered.
 

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. Although leaders did not always have the skills, knowledge and experience to fulfil their role, they did have the credibility to lead effectively. They did so with integrity, openness and honesty.

Although there was a manager in place, supported by senior staff, they were not registered with CQC. The service had not had a registered manager since July 2025. The manager intended to apply for registration in the future.

Staff told us leaders were open and honest, and they were able to contact them when needed. Team leaders had received appropriate training and ongoing development programmes relevant to their roles.
Although some improvements had been made following our previous inspection we identified 3 continued regulatory breaches. Concerns had also been identified in relation to notifications of allegations of abuse. This meant some development was needed in leaders’ skills and knowledge to lead effectively. The manager was very responsive and accepting of any points raised by the inspectors during the assessment.
 

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

Staff told us they felt comfortable in speaking up and raising issues to senior staff. The provider had a whistleblowing policy in place and staff had received training in line with this policy. The registered manager demonstrated an open approach in their engagement with staff and acted to address their concerns when known. Staff knew who and what to report both inside and outside of the service and felt able to do so. A staff member said, “All the issues we've had [the manager] is able to listen and get them fixed.” The manager told us, “Encourage them [staff] to speak up, if it doesn't feel right, it probably isn't.” The manager had supported staff through an investigation following a whistleblowing.
 

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.

For example, the manager demonstrated how they made reasonable adjustments to staff’s supervisions, competency checks and training programmes, to ensure staff were treated fairly and given appropriate support in their role. The provider also supported staff with their religious needs.
 

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider submitted an action plan to CQC regularly as part of the registration conditions following our previous inspection to support the development of robust governance systems. However, governance systems remained ineffective in identifying all shortfalls or driving improvement in all areas. The provider's internal processes had not identified issues found at our inspection, including where there had been continued breaches in 3 legal regulations in relation to safe care and treatment, fit and proper persons employed and good governance. For example, care plans were reviewed annually or if there was a change in a person’s needs or if a social worker review happened. However, these had not identified the shortfalls in some risk assessments.

Internal audits had also not identified CQC had not been notified of all allegations of abuse and all required pre-employment checks had not been completed. This meant timely action had not been taken to address risk and quality issues. Quality monitoring reviews with service users were planned quarterly and documented in their files when complete. There was a business continuity plan in place with people prioritised due to their needs using RAG (red, amber, green) rating. The manager told us they have daily handovers for staff which worked well. These had good detail and were relevant to people’s care and support. Staff said it the service were improving with the new manager.
 

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.

There was evidence of partnership working with key stakeholders, including commissioners, other providers and health professionals. The service worked with social workers and occupational therapists to get new equipment in if a person’s mobility declined. Senior staff also contacted GPs and district nurses to follow up on their condition and gain more information. The manager had organised a film night for people with tickets and food, to make the experience like going to the cinema. The manager also planned other events and activities to bring people together. This helped to promote positive outcomes for people using the service.
 

The provider was motivated to work towards continuous learning and improvement across the organisation. The manager told us they had an action plan with areas of improvement such as morning visit times. Although the provider was motivated to learn and improve the service for people, their overall ambition was limited by the lack of established risk and effective quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning.

There were continued concerns from the last inspection, a failure to implement good quality across the service and make improvements to meet good standards and regulations.
However, we found a number of areas in which the manager had made service improvements. The manager had put in place extra information sheets for people’s medical conditions and medicines to give more information to staff. The manager had recognised where some improvements were needed and had taken action to address issues and concerns. This included improving communication with relatives by setting up meetings. Feedback and updates were given at team meetings where staff told us they also had an input. Staff said having care plans on their devices would help as they currently had this in people’s files in their homes. The service had also met 3 of the 6 regulations they were in breach of following our previous inspection.