Radcliffe Manor House

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 requires improvement. At this assessment the rating has changed to inadequate.

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 service was in breach of legal regulation in relation to safe care and treatment.

This service scored 38 (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. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Records we viewed did not consistently show there was a proactive culture regarding health and safety incidents or concerns, and that these had not been effectively reflected upon and used to drive improvement.

Staff understood reporting systems and recording processes, however systems and processes for recording were not always completed. For example, there were multiple gaps in the recording of daily care for people. This meant we were not assured that people were receiving care as they should and therefore putting them at risk of harm.

Staff told us they reported concerns; however, these are not always followed up and outcomes were not shared. The provider was aware of the multiple concerns relating to staffing from multiple sources including people using the service, their relatives and staff but had not acted on any of these concerns.

Management did not always listen to concerns raised by staff. Staff told us they did not feel reporting concerns were valued. They had reported to management about how staffing levels impacted on their ability to provide person centred care, however action was not taken. This meant the provider missed key opportunities to learn and improve the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

People told us that GP and nurse visits were arranged as required. Optician and dentist visits were available, but with a reliance on family to arrange a visit to a local specialist. A chiropodist paid regular visits as did a hairdresser.

Staff we spoke to were aware of how best to support people; however care plans were not always reflection of people’s needs. We were told by a staff member, “Sometimes we don't hear if people's needs have change. Information on handover isn't always correct”. If a person required a hospital admission and information was shared, information would not have always been correct. This meant hospital staff would not have clear guidance on how a person liked to be supported.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

There was a record of safeguarding incidents which showed action had been taken, however this did not provide information on what lessons had been learnt in order to minimise the incidents happening again.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found MCA assessments were not always completed or lacked the key principles of the Act to make best interest decisions. Mental capacity should be reviewed regularly in line with the Mental Capacity Act (2005), reassessing, and implementing best interests decisions and Deprivation of Liberty Safeguards (DoLS) application if applicable. We did not always see evidence DoLS were appropriately reviewed. For example, one person was referred for a DoLS assessment in 2023 and had not been reviewed since. This meant this person may be unlawfully deprived of their liberty.

As shown in this report insufficient staffing levels and staffs' ability to provider care that was not person centred, or within timely manner meant people were placed at risk of neglect and/or and harm.

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

We found staff did not have clear written guidance in place to ensure people were supported in a safe way and according to their needs. For example, a person who required support with their mobility needs had inaccurate information in their care plan. We also found a person with mental health needs had no Positive Behaviour Support plan in place despite periods of time when they were distressed. A PBS (Positive Behaviour Support) plan isa person-centred, proactive approach to understanding and managing challenging behaviour.

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

We found many large heavy wardrobes to be unsecured from walls in people’s bedrooms. This meant large heavy wardrobes could tip or fall, which increased the risk of harm to people. Balustrades were found to be too low, posing a risk to mobile people. We found one of the banisters at the top of one of the staircases to be very low. Service Users are at risk of harm due lack of control measures in place regarding low bannisters. The team leader told us there was a Service User who regularly shouted over the banister for help. There was no risk assessment in place to identify any risk reduction measures. We found several Service Users who had limited mobility and some with cognitive impairment who were left unsupervised with free access to stairways. The lack of risk reduction measures in place increased the risk that Service Users may climb stairs and fall. This placed Service Users at an increased risk of harm.

The provider was receptive to our feedback and acted promptly. They acknowledged the improvements required and demonstrated a commitment to people to improve the safety of the service.

There were insufficient staff on duty to ensure people received timely care and support to ensure their safety was maintained. We found on several occasions, there were no staff in communal areas or upstairs despite people being present in these areas.

We found that people had to wait a considerable amount of time for call bells to be responded to. We reviewed call bell audits for a period of time which showed that people frequently had to wait long periods of time to receive support as there were not enough staff to provide the care required. For example, we found during our visit that one person was waiting for 42 minutes for support, and another for over 30 minutes. People and their relatives had raised several concerns about staffing levels before our visit with no action being taken to review and increase staffing numbers. People told us, “There’ll be no staff in the lounge from now (10am) till lunch time...If you want the toilet, there’s no one to see or take you. The call bell is right over there so no one can reach it, or the water jug for drinks” and “When [person] wants the loo, [they] have to wait so long, often [they’ve] done it.”

We raised staffing concerns with the provider who acted immediately, reviewing staffing numbers.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had completed infection prevention and control training. Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment in a safe way. This protected people from the spread of infection.

There were clear processes and policies to ensure that the environment was kept clean and hygienic. This protected people from the spread of infection.

Since our last visit the food standards agency had completed a visit and had rated the service 5 stars on the 17 June 2025

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found topical medicines stored safely and found medicines to be stored securely and in accordance with recommended temperatures.

Staff told us they received training for medicine administration, and we noted they administered some people’s medicine covertly. However, we observed 1 person left unsupervised with medicine in their meal. This meant that another person could have eaten this food and ingested the medicine. This placed people at risk of harm.

The ‘as needed’ protocol lacked detail and best practice on how and when to administer medicines. People were asked if they would like any ‘as required’ medicines prior to them being administered. We observed a person being administered eyedrops at the dinner table.

We found spacers used with inhalers did not have a use by date and the labelling on them was unclear, we were not assured therefore, that spacers were single person use. This meant people were at risk of cross contamination and infection. We made the senior aware who said that they would order new ones. Spacers help to ensure that medicine reaches the lungs where it's needed. Since raising the concern regarding labelling with the provider, action has been taken to address this and evidence seen of correct labelling.