Radis Community Care (Waverley Court)

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 newly registered service. This key question has been rated requires improvement. 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 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

While accidents and incidents were reported, recording practices were inconsistent. The service used different paper forms alongside electronic reports for March, April, and May 2026. This meant the depth of information collected varied and records could not always be located. An accident and incident tracker collated information. However, this did not record all accidents and incidents that were reported. This meant the provider could not be assured effective actions had been taken in all incidences or that potential safeguarding concerns were identified.

Actions taken to mitigate risks or to monitor for patterns and trends was not evidenced. Lessons learnt were not consistently evidenced to show learning from safety events and safeguarding concerns occurred were shared. For example, when a person had recently been admitted to hospital following a decline in their health condition. The provider had identified sharing of learning as an area for improvement and it was included in the service’s action plan.

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. They did not always make sure there was continuity of care, including when people moved between different services.

The service did not conduct assessments of people’s needs at the start of care delivery to ensure the service could meet people’s needs. There was a reliance on external assessments conducted by other organisations. This meant information about the person was not always identified, documented and included in people’s care plans and risk assessments. For example, around health conditions and people’s preferences in the delivery of care.

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.

A safeguarding tracker monitored what had been reported and action was taken in most cases. The safeguarding tracker covered concerns from March 2026 onwards. During the assessment, the service was unable to locate safeguarding documentation covering the period from January to June 2026. This meant investigation information and outcomes could not be reviewed. The service’s accident and incident tracker was inconsistent in terms of what was reported and actions taken. For example, 7 reported incidents and accidents in 2026 were not logged on the tracker. One incident in December 2025 was an allegation of abuse, no actions had been taken. This meant the provider could not be assured all safeguarding concerns were identified and managed appropriately. Identified safeguarding concerns had been reported to the local authority and Care Quality Commission (CQC) as required. A safeguarding audit conducted in May 2025 identified learning and clearer outcomes were required.

People told us they were happy and felt safe living at the service. A person said, “I’m happy to be living here. It’s where I wanted to be.” A relative said, “I can relax, knowing someone is checking in on [Name of person] regularly. [Name of person] is safer there than living on their own at home.” Staff received training in safeguarding adults and knew how to identify and report concerns. A staff member said, “Yes, we did have safeguarding training. We have to report [safeguarding concerns] straight away to the office, and management.”

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.

Risk assessments were not always up to date or in place for people's identified needs. For example, information about choking risks and skin integrity for 1 person was dated March 2024. The information in people’s homes was not always in line with information held electronically. This meant staff did not have accurate, up to date, information about people’s needs or how to manage risks safely. Two people recently admitted to the service had identified risks around sensory impairments, mobility and health conditions, but had no risk assessments in place at all. Risk information did not always include practical guidance for staff in the use of mobility equipment such as transfer aids, wheelchairs and slings. Topical creams with emollient related hazards lack documented risk assessments for 2 people.

Staff we spoke with who had worked with people for some time could demonstrate they were aware of risks around food and skin integrity and knew how to manage these. Staff highlighted where guidance was not in place to support the management of some people’s risks.

A business continuity plan gave guidance on how to manage unforeseen situations. Personal emergency evacuation plans (PEEPs) outlined the procedure to be followed for each person. It was unclear how this emergency information would be accessed by staff due to the lack of records where this was documented to support an evacuation. An out-of-hours system was available to support staff. However, no records were maintained to demonstrate when the on call system was used and any actions taken. Leaders planned to review the out-of-hours provision to ensure it was being utilised effectively and remained manageable for those operating it.

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.

Information in care plans and risk assessments did not always give full information of how staff should safely access and support someone in their home or use their equipment. For example, using a hoist sling or a wheelchair. Two people did not have any care plans or risk assessments about how staff should access their home and support them safely with their mobility and transfers.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Recruitment procedures were followed including Disclosure and Barring Service (DBS), right to work and reference checks. Health information was obtained; however, it was not always demonstrated how information was used to support the staff member in their role. For example, in accessing training or maintaining records. Equal opportunities information was gathered but not used in a meaningful way for the service as it was not analysed. Interview records were not always completed and did not fully show how the person had demonstrated suitability for the role. In January and May 2026 recruitment audits had commenced and had reviewed 3 staff files, identifying where further actions were required.

The provider had not ensured staff were fully supported through regular supervisions in line with their policy. Supervision is a dedicated time for staff to discuss their performance, development and well-being with a line manager. Five staff members had not received supervision in 2026. Medicine competency assessments were conducted. However, assessments of other areas of care or spot checks were not regularly conducted.

People told us staff were on time and care visits were completed as scheduled. Data we reviewed supported this. A relative said, “Staff are generally on time.” Another relative said, “The call times are OK. They [staff] stay the time.” People spoke positively about permanent staff. A person said, “Carers are very caring and can’t do enough for you.” Some frustrations were highlighted when people were supported by agency staff. A person said, “I don’t like it when the agency staff come in. But I don’t have agency too often.” People said the way the service had been managed had impacted staff. A relative said, “The longer serving carers are often run ragged and they have lost some good carers.”

New staff received an induction which included both an introduction to the organisation and shadowing of experienced staff. A staff member said their induction was, “Really good.” A variety of training was completed, both face to face and online. A person said, “The staff are well trained.” A staff member said, “They go through everything. The training is very good.”

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 received training in infection prevention and control (IPC) measures and had access to personal protective equipment (PPE). Guidance for some people was available in their care plans about PPE use. People and their relatives confirmed PPE was used as appropriate. A relative said, “[Staff] wear their PPE, gloves, aprons and sometimes masks.” Another relative said, “Carers are very good about infection control and they are always wearing their PPE.”

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. People’s medicines were not always managed safely. There was limited information in people’s care plans about what their medicines were for. For example, a health condition or pain relief. People’s preferences about how they wished to take their medicines was not consistently recorded. Where this was recorded, the provider could not be assured the information was up to date and accurate. For example, for 1 person this information was dated March 2024. Where people were prescribed ‘as required’ (PRN) medicines, protocols were lacking information of why the person may require the medicines, how they would communicate it was needed and maximum doses. A medicine record for 1 person was unclear if they were taken as required or daily. In addition, eye drops prescribed were not always clear if they were to be administered to both eyes or 1 specific eye.

One person was prescribed a transdermal patch requiring regular site rotation. However, the specific application site was not documented. This meant the provider could not be assured the medicine was administered in accordance with the prescription. Medicine risk assessments had previously been completed. However, information held in people’s homes was not kept up to date, which put people at risk if their medicines had changed. Two people did not have risk assessments for their medicines. One person had recently been admitted to hospital due to a deterioration in their health condition, with medicines management being a potential contributing factor.

Electronic medicine administration charts (eMAR) documented people’s allergies but did not give details of people’s GP. Staff codes were used, rather than staff initials. This meant the provider could not easily identify who administered the medicine without cross referencing the code. The provider said this would be changed in an upgrade to their current electronic system. No medicine audits were available for review during the assessment.

Staff received training in medicine administration and their competency was assessed. The provider had identified areas of medicine management for improvement in a recent provider report in June 2026. Although areas identified had not been specifically included in the service’s development plan.