Lifeways Community Care (New Barnet)

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 inadequate. At this assessment the rating has changed to 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 previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the service remained in breach of this regulation.

The service was previously in breach of the legal regulation in relation to safe and effective staffing. Improvements were found at this assessment, and the service was no longer in breach of this regulation.

This service scored 53 (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.

Overall, while there were early signs of progress, the provider had not yet established a mature learning culture where feedback, audits, and incidents reliably informed practice, strengthened staff competence, and improved outcomes for people.

There was some evidence the provider was beginning to develop a more reflective learning culture; however, this was not yet embedded or consistent across services. Staff told us they felt more supported by new management arrangements and were increasingly encouraged to raise concerns or share learning when things went wrong. Despite this, we found that learning was not always independently identified. For example, repeated inaccuracies in daily care notes, dysphagia (Dysphagia is a medical term for difficulty swallowing) documentation, and medicines records had not been identified or been addressed through routine oversight checks. The organisation was not always identifying learning from incidents, audit findings or practice errors that needed addressing. Therefore, they did not always mitigate risks or proactively recognise opportunities to drive improvement.

In addition, although the provider had introduced new systems such as the electronic care planning platform, these were not yet being used effectively to support continuous learning, reflection, or quality improvement.

The provider did not consistently work with people and healthcare partners to establish and maintain safe systems of care. Monitoring and management of people’s safety were not always effective, and continuity of care was not consistently assured.

At the time of our inspection, the provider did not have a policy or clear guidance in place to support people when they required hospital care in an emergency. This meant staff did not have consistent guidance about when they should accompany a person, how risks should be communicated to hospital teams, or how care responsibilities should be managed during a transfer. The absence of such a policy posed a risk that people may not receive safe or coordinated support during acute health episodes, particularly those with complex needs or communication difficulties.

Following our feedback, the provider developed and implemented a hospital transfer policy to clarify staff responsibilities and ensure a more structured and safe approach to emergency admissions. While this was a positive step, further work was required to ensure the new policy was fully embedded, understood by staff across all services, and consistently applied in practice. This included working with commissioning teams to agree a safe approach when outside of the care agreement in place.

The provider had safeguarding systems in place and most staff we spoke with were able to explain how to identify and report concerns. However, when reviewing safeguard information about the service we found there was some conflicting views on the outcomes of incidents, between the provider and other stakeholders including commissioners of care, people and their relatives or people acting on their behalf. As a result, there was a lack of evidence that demonstrated learning from safeguards had been fully agreed, embedded and led to improved quality of care. These challenges highlighted the need for strengthened professional relationships, oversight and more consistent monitoring to ensure timely responses and robust safeguarding arrangements across all services.

Again, feedback was mixed from relatives we spoke with. One relative told us, “[Person] gets looked after very well. I pick them up on a Sunday. Their home is clean, [person] looks clean.” However, another said, “They are complacent. Is my [relative] safe. I’m waiting for the next thing to happen.”

Staff we spoke with were aware of reporting processes. A staff member told us, “I would speak with my direct line manager, I expect them to deal with it, if it was not dealt with, I would reach out to the area manager or I would raise to CQC.” Another staff member said, “I am a team leader, I would talk to the manager. If the service manager was not listening, I would go to the area manager. Or I would go to the safeguarding team.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Clinical risks were not always monitored effectively. For example, monitoring tools, such as fluid charts were not routinely checked or evaluated by senior staff to identify shortfalls, meaning early signs of concern were not always recognised or escalated in a timely manner.

We identified inaccurate recordings by staff relating to two people’s prescribed IDDSI (International Dysphagia Diet Standardisation Initiative) levels. IDDSI is a globally recognised framework that ensures food and fluid textures are modified appropriately for people with dysphagia (swallowing difficulties). Using the wrong texture level can place people at increased risk of choking or aspiration.

In one support plan, staff consistently recorded an incorrect IDDSI level despite the level set out in the SALT (speech and language therapist) guidance. In another, staff recorded different and inconsistent IDDSI levels in daily care notes, creating uncertainty about what texture was actually being provided. Staff we spoke with during the inspection were able to describe the correct IDDSI levels, suggesting the issue was related to documentation rather than knowledge at the point of care.

When we fed this back, the provider responded proactively by meeting with staff to understand why inaccurate recordings were being made, and to explore how documentation practices could be improved. This was a positive step; however, at the time of inspection, the provider’s audit systems had not been effective in identifying and addressing these concerns at an early stage or preventing inconsistent care records from occurring.

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.

Emergency evacuation plans (PEEPs) were in place, which demonstrated staff had access to appropriate guidance on how to evacuate people safely in the event of an emergency. However, 2 evacuation plans in 1 location did not include a photograph, which meant they did not fully meet best practice standards for quickly identifying individuals during an evacuation. This was particularly relevant where irregular or unfamiliar staff were used to support services when usual staff were unavailable.

There were a number of outstanding maintenance issues across some locations brought to our attention by people using the service and their relatives or representatives. These included repairs and environmental improvements that had not been completed in a timely way. However, we saw evidence that service managers were actively escalating these issues to landlords who held responsibility for the properties and following these up when progress was slow. One relative reported concerns with a lift breaking down and we were able to identify the provider had requested a long-term solution from the landlord. Other relatives expressed concerns about maintenance responses being slow.

Despite these concerns, we also noted that improvements had been made in some properties, including better access to garden areas, which supported people’s wellbeing and enhanced their use of communal outdoor space.

The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to meet people’s needs.

Staffing was related to individuals commissioned care from local authorities and/or integrated care boards. The provider had increased oversight to ensure staff were not working excessive hours and told us when staff worked a certain number of hours; their systems would alert to senior staff. Staff we spoke with were happy with the hours they worked. One staff member told us, “I work my contracted hours. I will occasionally do overtime to cover sickness/leave.” Another staff member said, “My contract 37.5, 3 or 4 days. They ask if we want to do extras. There is no pressure, they told me I cannot do too many extra. Staffing is much better, a lot better. They always get agency if they need it.”

Feedback was mixed about the quality and competence of staff supporting people. A relative told us, “Staff are well trained to look after [person] as far as I am aware.” Another relative said, “I don’t think they have a clue about autism, learning disabilities or challenging behaviour.” However, other feedback was positive, including, “Yes, I think they are trained. They do shadow shifts with other staff before they start properly.” Another relative said, “[Person] has 3 staff who have been with them a long time. They know [person] well.”

Staff were positive about the training they received. A staff member told us, “I did my medicine last week. I did handwashing and epilepsy. We had Autism and Learning disabilities, safeguarding." Another staff member said, “It does help me to do my job well. We have time to complete training, and we get paid for this. We have had Autism and Mental Health training recently.”

Staff recruitment followed the provider’s procedures, ensuring appropriate vetting before employment. Induction processes included shadowing experienced colleagues and completing training.

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.

Infection prevention and control policies were in place, and staff had received appropriate training. Staff confirmed they had access to personal protective equipment (PPE), such as gloves and aprons, to reduce the risk of infection. Relatives were overall happy with the cleanliness of the home environment. A relative said, “[Person’s] home is clean and tidy when they visit.”
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Although people, relatives and staff told us they had no concerns about medicines management, our review of medicines records identified a number of shortfalls. When we carried out medicine’s reconciliation in some SLSs, we found discrepancies where stock counts did not match the amounts physically present. In other cases, carry forward figures were missing, which meant we were unable to reconcile stock accurately and account for whereabouts of all medicines. As a result, we could not be assured that medicines had always been administered as prescribed.

We found instances where prescribed medicines were not included on current MAR (Medicines Administration Record) charts. Although some of these were PRN (as required) medicines that had not been used recently, all prescribed medicines should appear on the MAR to ensure oversight, accuracy and safe administration.

There had been positive progress in reducing the use of PRN medicines. PRN protocols and effectiveness charts had been put in place, and the provider had introduced stricter controls around their use, including a requirement for managerial authorisation before administration.

Despite improvements, while medicines audits were in place, these had not identified the issues we found during inspection. This indicated that audit processes were not sufficiently thorough or consistently applied to identify and manage potential shortfalls and ensure safe medicines management.