Lifeways Paragon Limited

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. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to good governance.

This service was previously assessed in 2018 under a different registered address. The overall rating awarded at the provider’s previous address in 2018 was overall good. The service changed address in 2022. This is the first assessment and rating of the provider at their new address.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider’s oversight of the service was ineffective. The governance systems in place to underpin a clear shared vision, strategy and culture of good quality care were not robust. The process in place to identify and address shortfalls in service delivery were ineffective and did not ensure the quality and safety of the service met regulatory standards, or the challenges and needs of the people they supported.

The provider was also operating outside the scope of their registration, supporting people with nursing tasks regulated as Treatment, Disease, Disorder and Injury (TDDI). They were not registered to provide TDDI with CQC and we found serious shortfalls in the provision of these activities. It was clear the provider did not have clear governance framework, strategy or culture for ensuring the provision of these activities were safe and well managed.

As a result of the above failings, we were not assured the provider complied with recommended models of care or best practice recommended by CQC’s Right Care, Right Support or Right Culture guidance NICE and NHS England or legislation such as MCA/DoLS in order to ensure the right vision, strategy and culture was embedded within service delivery.

The provider did not have leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

The provider did not demonstrate they fully understood the context in which good care, and support should be delivered. There were shortfalls in the care of some people as the provider had not ensured the delivery of care reflected best practice guidelines and legislative requirements such as that set out by the Mental Capacity 2005 and the Health and Social Care Act at all times. This highlighted leaders did not fully understand the context or standards expected of services supporting people living with a learning disability, autism or other complex health conditions.

When asked, the regional manager and registered managers at the service did not have adequate knowledge of people’s needs and care and could not explain why shortfalls in people’s care were identified during CQC’s assessment. We found their ability to do so was hindered by the provider’s audit programme which failed to focus on the delivery of day to day care and the quality and safety of provision at the right level.

Some aspects of service delivery did not adhere to the provider’s own organisational policies for how support should be delivered. For example, the provider failed to adhere to their own delegation of health care tasks policy to ensure the basic nursing care in support of people’s PEGs was stringently managed to prevent harm. This resulted in some staff being expected to complete tasks they were not adequately trained, monitored or registered with CQC to provide.

Staff told us local leaders were supportive and visible. They told us they were approachable, open and operated with integrity.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt able to speak up and raise any concerns related to the service, people’s care or their own employment and working life. There were safeguarding and whistleblowing polices in place to guide staff on who to raise and report concerns.

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.

Staff told us they were treated equitably and fairly. They told us the provider, regional and local management teams were supportive, and staff morale was good. Equality and diversity was reflected in the workforce. The provider had policies and procedures in place to promote workforce equality, diversity and inclusion. This included ensuring staff with protected characteristics under the Equality Act 2010 had equal opportunity and equity in their working life.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had a tiered system of governance based on 5 levels of audit from front line service delivery to executive management. Each tier was responsible for quality checking the tier underneath it. Whilst this at first glance appeared to a robust system, the actual detail and quality of the audits undertaken at each tier were not robust.

The audits we reviewed lacked sufficient detail of what was audited to enable the provider to quality check the audit was robust and properly completed. We also found the majority of audits were positive, failed to identify widespread serious shortfalls identified at this assessment and therefore there were missed opportunities to mitigate the serious risk of harm or make improvements.

A new electronic system for care planning and the recording of people’s day to day care had been implemented. Phase 1 of the introduction of this new system was to be focused on ensuring information from people’s paper based care records were successfully transferred on to the new system and staff trained in its use. Phase 1 was commenced in March 2025 and reported by the provider as completed by June 2025. We found however Phase 1 had not been completed appropriately or quality checked as completed successfully by the provider. This resulted in the use of this system being inconsistent and poor, with staff using duplicate systems (both paper and electronic) to assess, plan and monitor people’s needs and care. This duplicity impacted on the quality, accuracy and consistency of record keeping, making it difficult to keep track of people’s care.

When asked about this, regional and registered managers appeared to be aware of the duplicity of the systems in use and the poor quality of record-keeping but did not show any evidence they had taken timely and effective action to address it.

The systems in place to manage medicines safely were inadequate. Medicines management did not adhere to best practice guidelines issued by CQC or The Royal Pharmaceutical Society and the audits in place to monitor the administration of medicines were not robust. This meant the serious shortfalls in medicines administration went un-noticed.

It was clear from the seriousness of the shortfalls found during this assessment that the governance and management of the service were inadequate.

We saw an improvement plan had been put in place by one Local Authority who commissioned the service. The provider had marked most of the improvement actions as completed however during our assessment we found this was not an accurate reflection of progress made.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not have robust systems in place to ensure the information shared with partners to learn and collaborate for improvement was accurate and up to date.

It was difficult to tell from people’s records how the service worked in partnership with other health and social care professionals, including the Local Authority, to ensure people’s experience of care was seamless. Record keeping in respect of people’s day to day care was poorly managed which impacted on the provider’s ability to share information and work in partnership with other health and social care professionals in support of people’s needs.

The provider failed to ensure it worked appropriately in line with its own policies, recommended best practice and commissioning guidelines in respect of the delegation of health care tasks to people who needed support with PEG care. They could not evidence collaborative working with NHS partners in relation to the delegation of these health care tasks.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

A culture of continuous improvement was not embedded in service delivery. The provider’s governance framework and systems did not enable the provider or registered managers to have a clear picture of how to make improvements happen, or to identify and address the shortfalls in quality and safety.

Service delivery did not reflect current up to date best practice guidelines in support of people living with a learning disability, autism and complex health conditions. This meant the provider failed to recognise and embed good practice recognised as beneficial to people using the service in order to improve their experience and achievement of positive outcomes. This did not show the provider was focused on and committed to continuous learning or being at the forefront of innovation, practice or research.