Archived: Radis Community Care (Caroline Square)

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created had not assured the delivery of high-quality care. A new manager had been in post from October 2024, but it was too early to assess the impact of this change.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke of division, bullying and distrust within the team. Staff had not consistently shared important information with management in relation to changes or concerns in people’s care and treatment. Whilst the provider had a vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, engagement, this was not embedded.

The management team were aware of the challenges within the culture of the service and the need to build trust within the team. The manager was taking steps to make improvements. These included regular staff meetings and a monthly staff clinic to encourage dialogue and openness, along with social events to build relationships within the team and with people using the service.

The service had struggled with leaders who did not always embody the culture and values of their organisation. Leaders had not always had the skills, knowledge, experience and credibility to lead effectively. We identified shortfalls in recording and process, for example the former manager had not followed the provider’s processes to ensure safe recruitment of new staff. Staff spoke of the former leaders ‘doing [their] own thing outside of the system’, others referred to a lack of ‘professional boundaries’.

The new manager had taken over the service in October 2024 and was recruiting to the senior team. One person told us, “I am aware of the manager she is approachable.” At the time of our visit one team leader was in post, with a vacancy remaining. In recent (January 2025) staff feedback gathered by the provider we read, “We have a new team leader. He is always willing to help and likes to get things done. He is doing an amazing job under the conditions he has.” At the time of this assessment it was too early to judge the effectiveness and impact of these management changes. One person said, “It is better now they have changed the manager and staff.” Another told us, “I am hoping now under new management things will tighten up a bit.” A relative said, “There are improvements there.”

People did not always feel they could speak up and that their voice would be heard. The system in place to seek and act on feedback was not embedded. Records did not provide evidence of action taken in response to people’s feedback. The manager acknowledged there had been no monitoring of quality reviews, but advised this was now being addressed. Following our visit, the manager shared a tracker they had devised to monitor people’s feedback and suggestions and to record the actions taken in response to it.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were challenges in the staff team, including reports of bullying and of distrust between longstanding and newer staff members. The manager was working towards an inclusive and fair culture by improving equality and equity for people who worked for them, but this was not embedded at the time of our visit.

The systems in place to oversee the service and manage risk were not robust. The provider had not yet embedded clear responsibilities, roles, systems of accountability and good governance. The audit systems for identifying, capturing and managing organisational risks and issues were ineffective and did not drive improvement. Information in people’s records was inconsistent or out of date, which placed them at risk of unsafe or inconsistent care. Staff records did not contain all required documentation in line with the statutory requirements. There was no evidence of call monitoring to ensure people received their planned support and to understand the impact of unscheduled calls on staffing levels. Where audits and records had evidenced non-compliance, timely action had not been taken to address and reduce the risks to people.

The provider did not fulfil their duty to collaborate and work in partnership, so services work seamlessly for people. They did not effectively share information and learning with partners or collaborate for improvement.

The lack of consistent and up-to-date information about people’s needs and care plans hindered the provider’s ability to effectively work in partnership so services worked seamlessly for people. One professional told us, “If someone’s needs change, then they should let us know, but they don’t necessarily.” The provider did not have a system in place to record visits from health or social care professionals to ensure their recommendations or changes to a person’s care and support were put in place. The absence of clear information about people’s needs and risks in their care meant they could not always share information and learning with partners or collaborate for improvement.

However, we also received positive feedback about partnership working. One professional described the new management team as “very receptive”. They told us there had been a lot of changes and they were receiving more positive feedback since the new manager and team leader had been in post.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. The themes of concern identified at this assessment closely mirrored those identified at our inspections other services run by the same provider in the area, published in early January and February 2024 respectively. For example, similar concerns over consent, medicines, person-centred care and governance were flagged. The provider had failed to evaluate and improve their practice by learning lessons and applying learning across their local services.

The provider did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. At the time of this visit, the manager was working address immediate concerns in people’s care and to identify and take action to ensure their needs were met. They told us there was a lot of work to be done and they, “Basically just need time to start again.” Only then did they feel it would be possible to think about enhancing the service.