Radis Community Care (Gloucester)

On this page

• 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to required 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 the governance of 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 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. We found the provider’s vision was not always fully understood by staff of Radis Community Care (Gloucester). One staff member said, “Managers are very approachable. We have the head office number we can speak to as well. We never see the owners of the care company.”

The registered manager had developed a clear and detailed vision for the service which was shared with staff who reported feeling engaged and supported by local managers. However, some staff indicated they received limited oversight or strategic direction from the provider and senior leadership.

Staff were supported to maintain and develop their professional knowledge and skills in line with continued professional development to support the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.However, there were aspects of the skills of the leaders which needed to be developed to enable them to lead with credibility. We found the registered manager and staff demonstrated a strong commitment to their roles and were aware of the challenges involved in delivering high-quality care. However, the registered manager needed to ensure their training was fully understood and embedded into their leadership and management practices in order to effectively lead the service and address areas of shortfall.

The provider had a positive culture where people felt they could speak up and their voice would be heard. Staff reported feeling confident to speak up and raise issues. Regular meetings were held to share information and promote transparency. There was evidence of a positive culture and staff felt their voices were heard and valued. Policies and procedures to support speaking up were in place and accessible to all staff.

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. The service actively promoted equality and diversity. Staff had access to an equality, diversity, and inclusion policy and had completed relevant training. Newly recruited staff completed a monitoring form. One staff member said, “Yes everybody gets the same opportunities. “This meant the provider was aware of the diversity of their workforce and could make reasonable adjustments as needed.

People and their relatives spoke positively about the management team.

The provider did not always 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.

The provider had failed to ensure effective governance and auditing systems were in place to monitor the service and drive improvement.We found governance and oversight of the service had not been consistently sustained since our last inspection. The provider's compliance team had assisted the registered manager to identify the services shortfalls and created a plan for improvement.However, the monitoring systems of staff development had not been fully maintained across key areas, including training, supervision, induction probation processes, and monitoring of care practices in line with the provider’s policies and guidance.

Medicines audits and lessons learnt after incidents had not been effective in driving and sustaining improvements in the management of some people's care and medicines. Further development of systems used to analyse accidents, incidents, safeguarding concerns, and staff rotas was required to identify trends, demonstrate learning, and support continuous improvement. The registered manager had not ensured all notifiable incidents were reported to the Care Quality Commission as required.

The registered manager had not fully understood their responsibility to assess the capacity of people with cognitive impairments to determine their ability to make decisions about their care, and adhere to the principles of the Mental Capacity Act (2005)

Policies and service user guidance required further localisation to reflect the specific needs and context of the service.

Staff were encouraged to attend meetings where updates and new information were shared.

Additional measures were required to implement efficient governance systems which would facilitate service monitoring and improvement.

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.

Staff and managers worked with stakeholders to understand the views and needs of people. Staff and managers understood their role and the importance to work in partnership with people, their relatives and associated health care professionals. Staff, their relatives and external partners ' views and concerns were encouraged, heard and acted on to shape the service and culture.

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. The provider and registered manager had identified shortfalls in the service and were working on their service improvement plan. However, further time was required to fully develop, implement, and evaluate the effectiveness of the service improvement plan. Not all of the service's shortfalls had been identified and incorporated into the plan.

There was a clear focus of ongoing learning and development across the service. Internal and external incidents and complaints were reviewed, and the insights gained were used to inform improvements. Lessons learned were shared with staff to support this process; however further time was needed to ensure improved practices were embedded into staff’s delivery of care.

Managers encouraged and prompted staff to undertake training to uphold high standards of care. The service continued to embed new systems and processes to strengthen governance and improve outcomes.