Radis Community Care (Oak Tree 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 newly registered 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 legal regulation in relation to governance at the service

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Regular spot checks were conducted in the service at different times to monitor the culture and staff meetings had recently been reintroduced, minutes evidenced an open environment where staff were encouraged to raise concerns to improve the service delivered.

The provider did not consistently demonstrate that leaders at all levels understood the context in which care, treatment and support were delivered, or that they embodied the values and culture of the organisation. Leaders did not always have the skills, knowledge, experience or oversight required to lead the service effectively.

The provider had not consistently met their regulatory responsibilities. The Commission had not been notified of safeguarding incidents, changes in management or concerns relating to infection prevention and control. This limited external oversight and assurance risks were being appropriately managed.

The service did not have sufficiently robust systems in place to ensure people’s needs were adequately assessed, monitored and reviewed. As a result, there was limited assurance timely action was taken to ensure people consistently received safe and appropriate care.

The manager had only been in post for a short period at the time of the inspection. However, most people we spoke with were aware of who the manager was. Team meeting minutes evidenced proposed changes to working routines to support improved communication and to help staff feel more confident approaching management and raising concerns.

Staff told us they found the manager approachable and fair. One member of staff said, “The manager is approachable and fair to all staff.” Staff were confident that the new manager in place had begun to implement change to support staff. This demonstrated some positive leadership attributes; however, systems and processes were not yet embedded to ensure consistent oversight, compliance and effective leadership across the service.

The provider promoted a positive and open culture where people and staff felt able to speak up and be listened to.

Staff told us they felt comfortable raising concerns and expressing their views. They said they felt supported to do so by managers, without fear of blame.

Although staff surveys were not in place at the time of the inspection, staff were regularly encouraged to share concerns and suggestions through supervision and team meetings.

Supervision records demonstrated staff were routinely asked whether they had any concerns or issues they wished to raise.

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.

There was evidence staff completed a health questionnaire when they commenced their role.

Where incidents occurred, staff were invited to attend meetings to review the incident and discuss learning. These discussions focused on learning and improvement rather than individual blame, which supported an open, transparent culture and encouraged shared learning.

The provider did not consistently demonstrate clear roles, responsibilities, systems of accountability or effective governance. They did not always act on accurate and up to date information about risk, performance and outcomes, nor did they consistently share information appropriately when required.

The provider had developed a service improvement plan following an assessment from the local authority, however, this was not fully effective as it had not addressed concerns around the issues raised by the local authority in full. The service not identified several of the issues found during the inspection, including gaps in medicines records, inconsistencies within care documentation and missing staff training. This limited its effectiveness as a tool to drive improvement.

There were gaps within audit and oversight processes, which reduced the provider’s ability to identify risks, monitor performance and ensure continuous improvement. Audits did not consistently record who had completed them or include clear actions to address identified issues.

There was no effective system in place to routinely review the quality of care plans and associated risk assessments. As a result, missing or incomplete risk assessments were not identified through governance processes, reducing assurance people’s needs were being assessed and managed safely.

Medicines audits had not identified significant risks, including people receiving ‘as required’ medicines intended for emergency use only, or medicines prescribed despite documented allergies. This indicated medicines management processes were not sufficiently robust. In addition, policies were not always followed in practice, and some were not reflective of how the service was operating.

The provider demonstrated an understanding of their duty to collaborate and work in partnership to support joined‑up care. Information and learning were shared within the organisation to support service delivery. However, there was limited documented evidence to support how joined up working was implemented into people’s care and support.

There was evidence of partnership working with professionals involved in people’s care. However, information and recommendations from these professionals were not always clearly reflected within people’s care plans. In addition, we were not always assured actions arising from professional advice were followed up in a timely manner. This reduced assurance partnership working consistently resulted in improved outcomes for people.

The provider had been working with the local authority to address concerns identified through quality monitoring processes. Managers described collaborative working to address areas for improvement. However, similar concerns were identified during this inspection, which indicated learning had not been fully embedded or sustained across the service.

Learning and continuous improvement were not consistently embedded within the service. There was limited evidence to demonstrate that the provider systematically used audits, monitoring or feedback to drive sustained improvement. Existing audit processes were not sufficiently effective in identifying shortfalls in care delivery.

Audits in place had not identified a number of the concerns we found with people’s care. As a result, there were limited recorded actions to address issues or improve people’s experiences. Where concerns about people’s care had been raised, we could not always see clear evidence action had been taken or reviewed to ensure improvements were made.

The organisation shared lessons learnt across its services. We reviewed the lessons learnt for Radis Community (Oak Tree House) and found clear records outlining incidents and identifying learning to improve people’s experiences. However, where learning had been identified, this did not always result in clear actions to further support people or reduce the risk of reoccurrence.

Managers acknowledged gaps in record keeping and oversight arrangements and told us they were working to improve documentation and governance systems. They explained the service was transitioning from paper‑based records to electronic systems and expressed a commitment to improving quality and driving improvement.

Some staff did not always feel when they raised concerns, or completed incident forms, that they received feedback or updates. Overall, although staff told us they felt listened to and leaders demonstrated openness and willingness to improve, systems were not yet effective in embedding learning across the service. Opportunities to reflect on practice, drive innovation and achieve sustained improvement were not consistently realised