Lifeways Community Care (Halifax)

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

At our last inspection we rated this key question Inadequate. At this assessment the provider had made significant improvements, and this key question is now rated good.

The provider is no longer in breach of regulation in relation to safe care and treatment or staffing.

People felt safe and were confident to speak up if something was bothering them. People said they were listened to. People lived in safe, comfortable homes where good levels of hygiene and infection control were maintained.

Systems were in place for all staff to take learning from accidents and incidents. Risks were managed positively to make sure people’s choices were respected and supported. People’s care pathways were well managed. Medicines were managed safely.

Staff were recruited safely and there were enough of them to meet people’s needs.

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This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s relatives told us staff responded well to resolve any issues or incidents. People felt comfortable to raise concerns and said that action was taken in response. One person told us about how they had told a staff member how to position a medical aid they used. The staff member had then informed other staff, and the person no longer felt uncomfortable and anxious.

Staff and managers told us about the workplace portal which all staff have access to and works in a similar way to Facebook. They told us how learning from incidents was shared on this portal.

One staff member said, “We always receive outcomes of anything we log and sometimes other incidents are shared for learning.”

Staff received training in lessons learned.

Staff said discussions were held regarding incidents and accidents and that they were encouraged to reflect and contribute.

Staff feedback demonstrated how they were fully involved in the learning culture embedded in the service by the provider.

We did not receive any information from partners in relation to learning culture.

Accidents and incidents were recorded and a lessons learned process completed for each one. Where appropriate the lessons learned were shared with all staff via the workplace portal.

Incidents involving people’s health and safety were referred to the provider’s health and safety department for full investigation and to establish what learning could be taken from the event.

Systems for audit fed into the process of learning lessons to drive improvement within the service. For example, staff at various levels completed peer reviews of each other’s services.

Managers completed training to make sure they understood duty of candour.

The provider had fostered and embedded a learning culture, which included the way accidents and incidents were learned from. We saw significant reductions in the number of these events as a result of these processes, people could be assured risks to their safety had been significantly reduced.

One relative told us it had been a long process when a person moved into the service. They said, “We were involved in everything” and went on to say how successful the process had been. Staff had taken time to work with all partners involved over an extended period to ensure they had learned about this person’s complex care needs in great detail, helping to ensure their transition into this service was safe and sustainable. Relatives told us how staff supported people with medical appointments and hospital stays.

The registered manager told us about the assessment and transition process for people moving into the service. This included working with family, health and social care professionals and the service’s own staff to ensure the process was effective. A compatibility review was completed to see if the person would fit into the environment and with other people living there. The person would visit the house they were moving into on several occasions including, where appropriate, overnight stays. There were reviews throughout the transition plan to make sure it was flexible and in line with the person’s needs. Staff talked about supporting people with healthcare appointments, both organising and attending to support, particularly where communication may be a challenge. For example, where a person was uncomfortable with aspects of health checks, staff worked in conjunction with healthcare professionals to learn how to complete the close contact parts of the processes with the professional checking the results, which reduced the person's anxiety and allowed the necessary checks to be completed.

We did not receive any information from partners in relation to safe systems, pathways and transitions.

Processes were in place to ensure safe systems, pathways, and transitions for people. Care records demonstrated care was planned and organised with people and partner organisations.

We saw examples of how people had been successfully supported during transitions to the service, accessing education and transitions to other services.

People had VIP passports which gave medical staff information about the person during hospital visits or stays. The VIP passports were also shared with the learning disability lead at the local hospital who inputted them onto hospital systems.

When we asked people’s relatives if their loved one felt safe, their responses included: “Yes, I think so. [Name’s]behaviour seems content and are really positive” and “[Name’s]not showing that [they’re] not safe. I think [Name] is safe otherwise [they] wouldn’t be there.” People told us they felt safe and had been empowered through support from staff to feel confident to raise any concerns. One person said, "My home is like a family. Sometimes we argue but all families do. I've learned how to speak for myself and how to listen to other people." Another person told us they were happy that “safeguarding procedures were followed well”.

The registered manager told us they were working with the adult learning centre to encourage people receiving support from Lifeways to attend a course on appropriate relationships and boundaries so that they themselves understand their own rights and how to complain.

Staff knew how to raise safeguarding concerns, including directly to the LA if necessary. One staff member talked about training they had received to understand the risk of closed cultures and the importance of speaking up with any concerns.

Staff understood capacity and supporting people to make their own decisions.

We observed people were comfortable and relaxed around staff. This was evident from the rapport built up between people and staff. We saw people walking in and out of house offices and chatting freely with staff. People were welcomed to attend the service’s main office to meet with and discuss any issues they may have with the registered manager.

Staff were vigilant to ensure people were not left waiting for care or exposed to any unacceptable risks.

Systems were in place to make sure people were safe and received the support they needed.

We saw an example of how staff had worked with the safeguarding team to support and enable a person to take control of an aspect of their life that they had previously been restricted in. The person told us this had enabled them to feel like the adult they were.

One person's goal was to go on holiday abroad as they hadn't been abroad since they were 2 years old. They had made a scrapbook of the journey towards this, including reviews completed with a specialist company to ensure access and safe care during flights, booking the holiday and the planning of activities they wanted to do. Staff had supported them with ensuring clinical input was included as necessary and that any potential risks had been assessed, and action taken to minimise them, whilst allowing the person to have the experiences they wanted. Staff had carried out extensive research around meeting this person’s care needs in an overseas setting.

Staff told us they read people’s risk assessments, and we saw they signed to say they had done this.

Staff knew the people they worked with well and supported them to manage risks. Staff gave an example of a person who wanted to get a tattoo. Staff had risk reviewed the situation with the person and their GP to ensure safety and were supporting the person to decide what they would get and where.

Staff clearly knew people very well and supported and encouraged them to do what they wanted as independently as possible.

Processes were in place to ensure risks were safely managed. Risk and needs assessments were clear and regularly reviewed and updated with the views of people, families and health professionals clearly recorded. Records of care delivery showed staff were adhering to care plans, for example, regarding diet, epilepsy and mobility. The service was working with health care professionals to make sure people they supported understood risks to their health and could make informed decisions about health screening. For example, arrangements had been made for health care professionals to show people the equipment that was used for bowel and cervical screening to give them opportunity to ask questions and understand the process.

People liked where they lived and said they felt safe there. They said appropriate equipment was available to support them. One person showed us booklets they had helped create for new staff and visitors as a pictorial guide for safely exiting the building in the event of an emergency evacuation. We saw the results of another person having designed their bedroom.

Staff said appropriate equipment was in place to support people and was checked before use and regularly serviced.

Properties were safe and well-appointed to support people to move around independently. Equipment had stickers to show when they were subject to a formal safety check and weekly safety check logs were up to date. Properties had appropriate access for the people who lived there. The homes were clutter free and met individual’s needs. For example, 1 person had a lounge that had minimal furniture and an activity table in front of their chair as this was appropriate for them.

Systems were in place to make sure safety checks were completed as required. Results of checks were inputted onto the electronic system to enable oversight by the registered manager and the area manager as part of their governance procedures.

People said they received the support they needed to manage their care needs, and that staff understood their needs well. They said they were able to do the activities they wanted, and staff were always available when they needed them. One person talked about the holiday abroad they were planning with staff, as well as theatre trips, discos and barge trips they had taken with the people they shared their house with. They said if there was something they wanted to do, staff always tried to arrange it

Staff said there were sufficient staff to meet people's needs. There were sometimes challenges, for example, if someone was off sick, but bank staff were used to provide cover. Staff at one property said they had the autonomy to arrange rotas to support people appropriately whilst also ensuring staff all received equitable time and weekends off.

Staff said they received a mix of appropriate online and face to face training to complete their roles and were able to request further training if needed. They particularly talked positively about in person training for end of life care, delivered by a local hospice. They also spoke about choke risk training that provided practical assessments to ensure understanding before needing to use any of the processes with a person.

Staff said they received regular supervisions and appraisals that reviewed practice and allowed for personal discussions.

There were enough staff to meet people’s needs and provide a high level of interaction and stimulation. People’s requests for support were met promptly.

Staff were recruited safely. Where possible people living at the service were included in selection interviews. Staff and people's personal interests were matched, to support relationship building. Staff induction included face to face and online training and shadow shifts with observations prior to being allowed to work independently.

Training compliance was monitored by the registered manager and staff who had not completed their required training were not able to work.

Staff were up to date with supervision with their managers.

Staffing hours were overseen by the registered manager to make sure people received their commissioned hours and any planned staff absence was covered.

Discussions were taking place with commissioners where staff felt people needed increased 1:1 hours and where waking night staff were needed due to people’s changing needs.

People were proud to show us their homes which they told us were always clean. People said support for personal hygiene was appropriate and timely.

Staff said they completed cleaning duties on shift and had rotas of activities to be completed daily and weekly; rotas were reviewed by the team leader and manager to ensure compliance. They said people were encouraged to help with cleaning where it was appropriate and safe for them to do so. Sometimes this was set as a personal goal, to support developing independence. Staff said they had access to appropriate PPE and cleaning products.

We found the homes were clean and hygienic and good standards of cleanliness were maintained.



Plentiful supplies of PPE and hand sanitiser were available throughout the homes.

All staff received infection control training which included observations of practice and competency.

Daily checklists in each house included hygiene and infection control. Further checks were made on all management visits.

People and staff were provided with information and support to make informed choices in relation to vaccinations. Best interest decisions were made where people lacked capacity.

Medicines were administered safely. The provider responded to our feedback in relation to there being no protocol for the use of one person’s inhaler that was prescribed ‘when required’. In addition, the dose instructions and administration record for 1medicine for another person was unclear.

Staff understood people’s needs regarding support with medicines. We didn’t find any inappropriate prescribing of medicines.

People were supported to attend their annual health check with their GP.

All staff had received medicines training and their competency to administer medicines was checked. Training included the importance of STOMP (stop over medication of people with a learning disability or autistic people) principles.

If staff made an error in relation to managing medicines, they completed more training, and their competency was re-assessed.

We saw medicines being managed safely.

Systems and processes were in place to support safe medicines management. Medicines were stored safely and at the right temperature.

Clear, detailed medicine records were kept for each person.

Medicine audits were effective in ensuring that medicines were managed safely.

There was a culture of reporting medicine errors and lessons were learned and action taken to improve medicines management.