Archived: Radis Community Care (Caroline Square)

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.

This is the first assessment for this service. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulations in relation to safe care and treatment, safeguarding, staffing and fit and proper persons employed.

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. Staff did not always understand concerns about safety and did not investigate or report safety events. During our assessment we identified concerns over people’s heath, safety and care that staff had failed to escalate to management. This meant risks had not been mitigated appropriately and people were left at risk of harm.

Lessons were not learnt to continually identify and embed good practice. However, from January 2025, the manager had documented a series of lessons learned, taken from within the service and from other services run by the provider and shared these with the staff team. These included concerns over skin integrity, medication errors and people not receiving necessary care, for example if they had been asleep at the time of a scheduled call. It was too early to assess the impact of this initiative.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not sufficiently manage or monitor people’s safety. For example, staff had not consistently followed updates from a person’s hospital discharge information to minimise their risk of choking. A healthcare professional told us, “Advice has not always been followed and [Name] has had to send through the same information. I am sure the Radis team are trying their best but they do always seem to be very rushed.”

The absence of clear information about people’s needs and risks in their care meant the provider could not make sure care was safe or that there was continuity of care, including when people moved between different services.

However, records did show staff had made appropriate contact with healthcare partners when concerns had been identified. One person told us, “If I needed a doctor, they would call one.”

Staff did not always recognise incidents of potential abuse and did not always escalate concerns to enable preventative action to be taken to ensure people were protected. This placed people at risk of neglect and possible harm.

Although staff identified a person was at risk of choking, they did not escalate their concerns which meant the person was at continued risk of harm. For another person staff had been requested to not attend on multiple occasions. The planned care included repositioning support and monitoring their wellbeing. This had not been escalated to check the person was safely cared for and whether they had the mental capacity to consent to alternative arrangements.

Incidents where people had told staff about a failure of staff to respond to their needs were not reported for investigation and preventative action where necessary. This placed people at risk of harm and abuse.

The provider had not ensured all staff had up to date training in safeguarding people from abuse. Whilst staff could explain what safeguarding was and said they would raise concerns to management, in practice concerns had not been escalated consistently. We could not be assured all staff were aware of their safeguarding responsibilities.

We received mixed feedback from people and relatives about feeling safe and protected. This included concerns about staff behaviours, lack of prompt action following incidents and a lack of confidence to raise concerns. However, people and relatives did report an improvement in confidence in the new management team.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not have appropriate guidance to understand how to support people safely. People with risks linked to catheter care, diabetes, dehydration and poor nutrition did not always have risk assessments to support their safe care. For example, staff we spoke with gave conflicting accounts of how they supported a person known to be at risk of choking. Actions to mitigate the risk of choking such as observation/assistance when eating and drinking were not followed by staff. Prescribed thickener for fluids was not always available. Although current concerns about choking had been identified by staff, they had failed to report these to managers.

Records did not evidence action was taken in a consistent way to mitigate known risks. Monitoring records were absent or contained gaps, meaning there was little or no oversight in areas such as food or fluid intake, urine output or the application of topical creams to prevent or relieve pressure injuries. Where staff had recorded concerns there was no oversight from management to ensure people’s safety. This meant risks to people were not always reviewed to identify changes needed to keep them safe.

We received mixed feedback from people and relatives about managing risk. Most people told us they felt safe with staff. However, others raised specific concerns including on continence care. One person told us they were only confident in certain care staff due to a previous incident. Another said “I am sixty percent happy with the care. They did not do a care plan until the summer (several months after starting support). They did not do my risk assessment until the day before the inspectors came yesterday so I have not felt secure.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff had failed to escalate concerns which increased the risk of fire. A person had lost consciousness during personal care on two occasions, but this had not been reported. Consequently the risk had not been assessed to consider how, given the person was a smoker, such an episode could put them and others at risk from fire.

The service supported people in their own homes. Communal areas were managed by the housing provider. A risk assessment was completed by the provider to identify risks in people’s home environments. However, these were not always updated to show risks had been reviewed and the information was current.

Equipment checklists were included in people’s care records. We found some checklists had not been completed or updated with regular safety checks. This meant people and staff could be at risk of using unsafe equipment.

The housing provider told us they were confident staff would inform them when they identified risks to people for which the housing provider had responsibility.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider had not ensured staff were effectively deployed to meet people’s needs. We received reports of calls for additional support going unanswered. Many of the calls recorded in people’s daily records were of a shorter duration than planned and some were attended by 1 staff member rather than the 2 planned. We received mixed feedback from people. One person said, “They [staff] say hurry up we have other people to get to.” Other people were satisfied with the support they received.

Staff had not always received effective support, supervision and development. They did not always work well together to provide safe care that met people’s individual needs. Some staff were unclear on how they should respond and record unscheduled calls for support.

Induction and training records did not demonstrate all staff had completed their planned induction or the provider’s mandatory training. Staff told us they received infrequent supervision. There was no evidence of regular appraisals to monitor staff performance and support their development.

The provider did not make sure staff were recruited safely. We found gaps in the pre-employment information required in each of the 4 staff files reviewed. The provider had audited their employment files but had not yet taken action to address the missing information.

The provider did not always assess or manage the risk of infection. They did not always operate effective monitoring systems to detect and control the risk of it spreading.

The provider carried out spot checks to monitor staff were using the appropriate Personal Protective Equipment (PPE) to prevent and control the spread of infections. However, records did not evidence these had been carried out regularly or consistently. People told us staff wore gloves when delivering personal care. Though the manager told us “Staff are now wearing aprons”, one person commented, “Staff sometimes wear aprons.” We could not be assured staff always followed safe practice.

We noted staff had been reminded of their infection prevention and control responsibilities by memo on 6 January 2025, to minimise the risk of spreading the flu virus. In addition, staff had been reminded about wearing correct uniforms in a meeting.

The service did not make sure medicines and treatments were safe and met people’s needs. Systems and processes did not identify and mitigate risks associated with medicines.

Systems and processes to safely administer and record medicines were not always in place. Care plans did not always identify and mitigate risks. For example, for a person prescribed a blood thinning medicine with a variable dose (a dose that changed, depending on the results of a blood test), it was unclear how and when the dose might be changed, how staff would be told or the bleeding risks staff needed to be aware of when the person was taking it.

There was no information to support staff when a person may need medicines prescribed ‘when required’, how often to give them or when they may need medical attention if not effective.

The electronic medicines record system did not always contain information about how to give medicines, such as the strength and formulation. Information was missing when people were prescribed medicines that must have a four hour interval between doses and people were receiving their doses too early, putting them at risk of harm.

People did not always receive their medicines as prescribed; we saw 3 people had missed 10 doses of their medicines, which may exacerbate their condition or put them at risk of harm. Staff carried out medicines audits, but these had not identified these issues.

Incident reports did not detail action taken to make improvements to prevent reoccurrence. Staff had received medicines training, but not all staff had completed online annual refresher training in line with the provider’s policy. We did not see evidence competency to administer medicines had been regularly assessed for all staff. Therefore, we could not be assured all staff administering medicines were trained and assessed as competent.