Radcliffe 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems were in place for the reporting and responding to any accidents and incidents. We were told and information showed that any concerns were discussed as part of the multidisciplinary meetings and debrief with staff. This included discussions about potential triggers, action taken and any further learning. One staff member told us, “Following an incident, debriefs are held with staff to discuss what went well, what did not go well, what could have been done better and how do staff feel.” Another said, “Team meetings will be held with the managers, to discuss what happened, why it's happened, and if policy and procedures were followed. We also discuss how to prevent it from happening again.”

A range of training was provided by the head of education and psychology team, supporting staff in developing the knowledge and skills needed to effectively support the young people in areas such as Education, Health and Care Plans (EHCP), positive behavioural support plans and distress management.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Effective plans were in place to support the young people when moving into the home. This involved opportunities for introductions as well as visits to the home and spending time with the other young person and staff. This also provided further opportunity for information about the young person to be gathered as well as making sure the placement was suitable and supportive.

Records also showed the in-house multi-disciplinary team (MDT) supported young people moving into the home ensuring a smooth transition as well as ensuring the right support was identified and planned for. In addition to managers and staff within the home, this also include a psychiatrist, occupational therapists, registered mental health nurses and a psychologist. Regular team meetings were held to monitor and review the support in place.

Additional records were in place to help ensure the young people received safe and effective care. This included a health care plan with relevant information about their health care needs and support the young person may require.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Lawful restrictions were in place through the Court of Protection and Deprivation of Liberty safeguards (DoLS). Restrictions were regularly reviewed exploring where these could be lessened to enable the young person to increase their independence, whilst ensuring they were kept safe.

Relevant policies and procedures were available to guide staff in safeguarding from abuse, Mental Capacity Act (MCA), and DoLS. This was supported by a programme of training. Staff were able to demonstrate their understanding of the Safeguarding procedures, MCA and DoLS. Staff spoke about keeping the young people safe, whilst respecting their rights and helping them to remain as independent as possible.

A missing person form, including a photograph, was in place and referenced the Philomena Protocol, which records key information to support the safe and prompt return of children and young people at risk of going missing.

Safeguarding concerns were notified to CQC in line with requirements.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service follows a ‘model of care’ that focuses on managing risk during a young person’s placement within the service. This is health care staff and supported by a wider multi‑disciplinary team.

A review of the care records showed detailed information regarding areas of risk and how the young people were to be supported in minimising such risks. Records included a positive behaviour support plan and risk management plans. These were kept under review through the MDT meetings, which explored the young person’s presentation, risk factors, warning signs and treatment and support plan.

Staff carried out regular observations to ensure the young people remained safe. Incident reports were completed where necessary and reviewed to identify themes and any actions needed to reduce or prevent repeat incidents.

Both young people described how they behave when distressed and the support staff provide to help them. One young person spoke positively about a pain management plan that had been introduced to help reduce distress when they were in discomfort. This also helped staff to understand the level of pain and provide the right support.

Staff said risks were clearly identified, assessed and planned for. Staff said they would use distraction techniques when in a heightened state of anxiety. One staff member said, “The young people have their risk review which is updated regularly. We have ligature mitigation management and Positive Behavioural Support (PBS) plans in place to help manage their risk.”

Environmental risks were also considered. Risk management plans and protocols for staff were in place regarding ligatures and self-harm. This was supported by staff training. Management plans were reviewed monthly and had been updated following the changes made within the home environment.

A fire risk assessment was in place. Staff had undertaken fire training and fire drills involving the young people. Emergency evacuation plans were in place in the event of an emergency arising.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home is a small, domestic-style dwelling. Communal areas included a lounge and dining kitchen, which offer areas for the young people to relax, spend time together, and prepare meals if they wished. Each young person had their own bedroom, which was personalised. The front door was kept locked due to individual restrictions in place to support people’s safety. We found the lounge area appeared sparse; this was due to previous incidents where property had been damaged. Work was being completed to address this.

Safety certificates were available for mains gas and electricity, portable electrical appliances, and the fire safety system. Regular internal checks were carried out, including fire safety checks, and health and safety monitoring were completed to help protect people’s wellbeing.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

A comprehensive programme of on-line and face to face training was provided for staff. Topics included specific training around the needs of the young people. These included, mental health, learning disabilities and autism, Prevention and Management of Violence and Aggression, MCA and DoLS, medication and safeguarding adult and children. A training calendar was in place outlining additional face to face training planned over the course of 2026.

A review of training records showed staff had completed a high number of on-line training courses within 1 day, for example the records for 1 staff member showed they had completed 26 courses, others ranged between 13 and 16. It was unclear how effective the training was or whether staff understanding had been assessed.

Staff told us they received the induction when they started work. We were told, “An induction was conducted and this involved company policies, procedures and goals” and “I received an induction and was assigned a mentor. I also did some mandatory training and after that did some shadowing before resuming full shifts.”

Staff confirmed they completed both online and face to face training. Training explored a wide range of courses relevant to their role, this includes topics such as Prevention and Management of Violence and Aggression(PMVA), fire Safety, medication training.

Staff also said they had individual supervision and teams meetings enabling them to discuss their work. Staff commented, “Team meetings are conducted every 3rd Monday in the month where everything concerning the role is discussed, reflective practice held, check training done, as well as discussion about recent incidents” and “Meetings are held monthly, where the manager will ask about staff wellbeing, and any support needed.”

Staffing levels were sufficient, recruitment processes were safe, and appropriate right‑to‑work checks were completed for overseas staff.

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.

Young people were encouraged to take part in cleaning tasks within the home. Policies, procedures, and training were in place to promote good hygiene standards and food safety. Records were maintained, and any issues were discussed in team and young people’s meetings, with agreed actions identified.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

A safe system was in place for managing and administering medicines to young people. A sample check of records and medicine stocks, including controlled drugs, confirmed these were correct. Temperature checks were recorded for the fridge and room and were within range. Regular stock checks and audits were also completed by senior staff and the supplying pharmacist to ensure a safe system was maintained.

Records showed staff had received appropriate training and competency checks to ensure medicines were administered safely and as prescribed.