Lifeways Community Care (New Barnet)

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

This service scored 50 (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 communicated a clear shared vision, strategy and culture; however, this was not embedded, reflected or achieved consistently across services. It was not clear why or if the provider had analysed the reasons for significant difficulties in recruiting and retaining staff and leaders who could support improvements. There were challenges with professional relationships and clarity of expectations/agreed standards. Whilst there was an action plan, deadlines continued to be missed, for example we were advised care plans, risk assessments and records would all be completed and reviewed by November 2025, but concerns and technical challenges meant this continued to be an unmet action in some services at the time of this inspection. The provider’s representatives stated they had access to internal resources including quality improvement teams who were supporting staff to drive improvement. No internal root cause analysis had been shared with CQC, but we were made aware that the provider had served notice on one SLS scheme and a commissioner was replacing them with another provider.

While there was direction in place, leaders did not always demonstrate a full or consistent understanding of the challenges faced by people using the service or the specific needs of local communities. This variability meant that the intended culture and strategic aims were not always embedded in day to day practice across all locations, resulting in inconsistent experiences and outcomes for people. Comments from relatives included, “They all work well together from what I see. Things have changed for the better. Even the staff sense that. They are supported more.” and “No I would not recommend this service. Nothing has changed.”

Not all leaders demonstrated the skills, knowledge or understanding needed to lead effectively across the service.

While leaders shared there was a commitment to working to improve standards, this was not always consistent or effective. Frequent changes in management had contributed to instability. The provider reported their aim to ensure locations had a stable senior team and told us they were actively recruiting to ensure this happened. An application to register a manager to oversee the locations had been received by the Commission. However, the appointment had taken over 12 months with more than one person being identified to take on this role in that time. In the interim an area director had oversight of the service improvement plan with support from the members of the provider’s senior leadership team. Assurances had been provided to the Commission that there were enough resources to ensure improvements were being made. This included quality improvement teams and external auditors. Given this we remain concerned and were not assured about the effectiveness of the provider to appoint and retain leaders with the skills needed in complex services.

Most staff felt listened to and valued and reported improvements in their support while others said issues they raised were not always followed up or communicated back to them. As a result, leadership was not consistently compassionate, inclusive or capable of ensuring high quality, person‑centred care across all locations.

People did not always feel they could speak up and that their voice would be heard.

While some relatives told us they felt comfortable raising issues, this was not consistent across SLSs, and others said they were unsure whether concerns would be taken seriously or lead to meaningful action. This lack of consistency meant people and relatives did not always have confidence that speaking up would result in improvements to care, which limited the provider’s ability to identify issues early and learn from feedback.

Most staff told us they now felt more confident to speak up and were encouraged to do this. A staff member told us, “I feel I am able to speak up and raise any concerns; they are listened to.” Another staff member said, “We are encouraged to speak up, [service manager] encourages everyone to speak up and be outspoken.”

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

Feedback from staff during this assessment indicated they felt their support had improved and they were treated equally.

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.

Oversight processes did not always identify emerging risks, and audits were not sufficiently robust to detect concerns relating to risk, medicines management, care planning or record accuracy. Similarly, inaccurate or inconsistent daily records had not been picked up through internal audits. These gaps showed that the provider did not always act on the best information about risk, performance or outcomes, and governance systems were not yet effective in ensuring sustained improvement. While a tiered system of audits was completed, they were had failed to identify gaps, inconsistencies and the concerns we identified in the inspection.

The provider did not always effectively collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Partnerships with external agencies, professionals and community organisations were not always effective. Partner agencies remained concerned that the provider’s progress had been slow and there were conflicting information and views about the quality of care and improvements being made. This resulted in some break down in communication and poor professional relationships, with a lack of agreement about how care should be provided and monitored.

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. They did not always actively contribute to safe, effective practice and research.

Opportunities to learn from incidents, concerns, audits and feedback were not consistently identified or used to drive change effectively. Innovation was not embedded across services, and improvements made in some locations were not always shared or adopted elsewhere, leading to variation in practice.

The provider was focused on improving the service, getting the basic care requirements right, and being consistent. They shared the intention to develop once the service became more stable.