The Radcliffe

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

In discussions with staff and leaders, it was clear there was not a shared view on what good quality care looked like. The governance system in place to oversee the quality of the service was ineffective. We found widespread issues across the service which impacted upon the care people received. Whilst we observed staff were kind and caring towards people, the inaction of the service in respect of incidents, risk management, medicines management and care planning placed people at risk of harm. Prior to our inspection, the local authority raised concerns about the management oversight of the service. They had been raising concerns with the service but many of these concerns still remained by the time of our visit. This meant we were not assured that an effective system was in place to bring about improvement. Staff meetings were taking place and some relevant aspects were discussed and direction given to staff, but we found no evidence of this was monitored and how the manager ensured the issues identified were acted upon. There was a complaints process in place and the registered manager was able to explain us the steps they would take if they received a complaint. There were no records of complaints received by the service. People told us they did not have complaints about the service. The provider was extremely responsive in acting on the concerns we identified during our inspection. On our inspection visit, we found improvements had been made in relation to staffing, medicines, managements of risks, staff’ training and plans were in place to address the other areas of concern.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from staff with some saying they felt involved in the organisational direction and others feeling removed from any decisions being made. Many staff felt that the new manager had tried to make improvements, and acknowledged this was a difficult task.

Staff meetings were taking place and some relevant aspects of care delivery were discussed and direction given to staff. However, we found no evidence that this was monitored to ensure staff practice reflected the direction they were given. We could also find no evidence of how the manager ensured the issues identified were acted upon. For example, issues with frequency and quality of personal care had been identified in a team meeting in June 2024, and again during a contracts monitoring visit completed by the local authority in July. When we completed our inspection visits, we continue to find this was an area of concern. Although most people and relatives shared positive feedback about the care received, we found concerns about several areas of the care provided and in our conversations with staff and management, we found there wasn’t a shared view of what good quality care looked like.

The registered manager told us they supported staff. However, during this inspection we found staff were not always given all the training they required to do their jobs safely and there was a lack of risk assessments and care plans to ensure staff had relevant information about how to care for people safely.

The registered manager told us they supported staff. However, during this inspection we found staff were not always given all the training they required to do their jobs safely. There was also a lack of risk assessments and care plans to ensure staff had relevant information about how to care for people safely.

Staff felt that the registered manager had made improvements and encouraged them to speak up. However, in our review of staff meetings we did not see evidence of staff feeling confident to raise issues. The registered manager told us they had not always felt confident in raising concerns about staffing levels with the nominated individual.

There was a complaints process in place and the registered manager was able to explain the steps they would take if they received a complaint. There were no records of complaints received by the service. People told us they did not have complaints about the service. Residents meetings were taking place for people to give feedback. However, we found a lack of processes in place to ensure people and relatives were involved in planning and reviewing the care people received.

Most of the feedback from staff indicated they felt supported. However, we found staff had not always been provided with the training to complete their jobs safely.

The processes and procedures in place did not always promote staff equality and inclusion. Although there was an equal opportunities policy, we found staff were not regularly supported with supervisions where they could discuss any concerns in this area.

The registered manager and nominated individual had poor management and oversight of essential areas of care delivery. The audits in place had not been effective. The registered manager left their post after our second inspection day and the nominated individual acknowledged their lack of oversight at the service.

During this assessment, we found people did not always receive safe and person-centred care due to widespread failings in the management and oversight of the service. We found the management and oversight of essential areas of care delivery was not always robust or effective. Governance systems in place had either not identified or addressed concerns found. For example, people’s care records were not always complete, accurate or contemporaneous. Medication audits not identified issues we found. We found considerable issues with call bell response times which had not been identified. There was a lack of learning and improvement. The service had received feedback on concerns from a local authority monitoring visit but had not acted upon these shortfalls before our inspection. The registered manager and nominated individual were responsive to our findings and started to make improvements on risk assessments and care plans after we told them of the concerns we found.

Some people accessed the community at times, during activities with staff or family members. External professionals visited the home to meet the needs of people. However, due to reviews of care not always taking place we could not be assured that people's care was reviewed regularly with the input of relevant partners.

Our conversations with staff and leaders raised no concerns about partnership working and links with the community.

Partners were working with the home to identify concerns and make improvements to the service provided. The nominated individual was receptive and collaborated with the support being offered.

The service was not working effectively with local partners as concerns identified through external reviews had not been used effectively to drive up the quality of the service.

The registered manager did not have a good understanding and oversight of how to analyse incidents to identify patterns and trends. This meant they had not been able to identify and use this information to review staffing levels and people's care. This placed people at risk of harm from repeat incidents, such as repeated falls. Staff confirmed that they had received training via e-learning and had undertaken shadow shifts prior to starting to care for people.

Accidents and incidents were being logged. However, analysis was not effective in identifying and acting on patterns. This meant opportunities were being missed to identify patterns and take action to reduce repeat incidents. During this assessment, we found concerns with the high number of unwitnessed falls at certain times and the need to review staffing levels in line with this. This had not been previously identified.