Radis Community Care (Stanbridge House)

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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.

This is the first assessment for this service. This key question has been rated 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 service was in breach of the legal regulation in relation to governance at the service.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Delegation of some managerial tasks had been assigned to other staff. We found reviews of care plans, risk assessments and auditing had fallen behind schedule.

However, some staff were complimentary about the registered manager and felt there was a good culture in which they could speak up openly without fear of detriment. They were not, however, reassured that improvements or changes would be made.

People and relatives also told us they felt the manager was approachable.

The provider had inclusive leaders, but they did not always understand the context in which they delivered care, treatment and support.

Staff told us they felt unsupported by the senior leadership team [area manager, regional manager]. The provider was responsive to the feedback we raised during the inspection, including the failure to raise certain notifications as required.

Staff told us, “I have some concerns about the lack of support from upper management [area and regional manager], despite two team leaders leaving.” The senior management team received the formal feedback alongside the registered manager and stated improvements would be made.

Staff were able to speak up but had not been given the opportunity to provide formal feedback through surveys from the management team.

Although staff had had supervisions, there was limited evidence of them in their staff files and no evidence of any actions taken following them. The provider had a complaints log but it lacked evidence of actions taken. One complaint listed a staff discussion as an action taken but no evidence of any discussion was provided in staff meeting minutes or elsewhere. This meant that people and staff were not reassured that any complaints they raised would not happen again.

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

Staff told us that the workload was unevenly distributed due to cultural differences in the manner by which some staff delivered care and improvements were required to ensure equity in how staff working in the service were viewed and treated. The registered manager was aware of a situation in which certain carers were not allowed to visit certain people, which had led to an unfair distribution of care visits. The registered manager told us that some staff were abrupt in manner and could not visit certain people which had caused some inequalities and unhappiness within the team.

Staff had completed enhanced equality, diversity and inclusion training as part of their core induction.

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

Governance systems, processes and procedures that assessed risks, and monitored quality and safety were not effective. The provider failed to identify the shortfalls we found during this inspection and put people at increased risk of harm. There were no systems in place to effectively monitor and assess people’s needs as the registered manager had not carried out audits of people’s care records. We found records were incomplete and contradictory. Medicines were not monitored effectively. Medicine audits had not identified the concerns we found during inspection, such as missing information, no PRN protocols, and absent MAR charts. Staff files audits had not picked up the lack of risk assessments for those staff that were not recommended to work in the care role that they had applied for.

The registered manager did not always understand their responsibilities on when to raise safeguarding alerts and report statutory notifications to the CQC. This meant arrangements were not effective in monitoring and addressing shortfalls in the service.

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.

The provider was transparent and open to seeking and receiving support. The registered manager was knowledgeable about how to access services. They told us that they had a good level of communication between GP's, the district nurse team and the single point of access team. One professional told us, “Your team have been great to work with.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Surveys from people who used the service lacked detail or any directives and staff surveys had not been implemented. Management did not always investigate safety incidents fully and there was no record of lessons learned being delivered to staff. Team meeting minutes stated “lessons learned” with no further details. The provider’s service quality development plan did not reflect effective auditing of the service and did not contain robust action plans to drive improvement. People’s feedback was not analysed and remedial action taken. We did not see any evidence of innovation across the service or inspired ways in which the provider delivered care to improve the outcomes and quality of life for people who use the service. The provider did not always appear to learn from past events.