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 in service leadership, management and governance which 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 provider was in breach of a legal regulation in relation to good governance.

This service scored 61 (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 a shared vision, strategy and culture.The culture of the service was open and transparent. The provider was honest about shortfalls found at the last assessment and demonstrated the action they had taken to improve. The providers strategy and vision was clearly outlined in their policies and ongoing improvement plans. Overall, the culture promoted the delivery of care that fit the Right Support, Right Care, Right Culture model.

The provider had inclusive leaders, but they did not always understand the context in which they delivered care, treatment and support. For example, quality assurance systems had not always been effectively implemented to ensure risk to people’s health and safety were mitigated. We identified shortfalls in areas such as medicines management and the completeness of care planning and delivery records which had not always been identified by the providers monitoring systems.

However, the provider had capable, compassionate and inclusive leaders who demonstrated a clear commitment to improving the service. They responded positively to regulatory feedback by taking action to reduce risk, this included updating care plans and ensuring personal evacuation plans were available in case of an emergency. While we had confidence in the registered managers ability to reduce risk following our feedback, improvements were needed to ensure they retained effective oversight and developed a more robust monitoring system that was proactive in identifying and reducing risk in a timely manner.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to policies which guided them on the processes they should follow to raise concerns. All staff told us they felt supported by leaders and felt they were approachable, and they could share concerns openly.Comments from staff included, “I speak out if somethings not right. I’ve raised things and they have been addressed” and “I have no problem at all about raising concerns, I believe the right action would be taken.”

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. Different cultures, faiths and backgrounds were represented within the staffing team. Difference was respected and celebrated. Staff told us they were treated fairly and felt included in the running of the service as they felt their views were sought, listened to and respected. Comments from staff included, “Yes, very fair. [Leaders] are supportive, approachable and visible” and “No concerns. Manager will support flexible working such as for appointments or other personal situations.”

Theproviderdid not always implement effective systems to ensure good governance. They did not always act on the best information about risk, performance and outcomes. While some improvement to auditing processes were found, further improvement was needed to ensure all audits and checks were effective at identifying and addressing concerns. For example, audits relating to medicines, care plans and records of the care provided had not always identified the shortfalls we found during the assessment. In addition, overall audits completed at people’s individual homes were not always effective. Where concerns were identified, records did not always show what action had been taken to improve.

However, the provider was responsive to our feedback and took actions to strengthen processes to reduce risk in areas such as medicines management and care planning.

Theprovider’s systems did not always support effective partnership working, so services workedseamlessly for people. Records relating to people’s day to day care such as nutrition and hydration and personal care were not always well maintained. This increased the risk the provider would not be able to share accurate and complete information and work in partnership with other health and social care professionals in support of people’s needs. Partners told us the provider did not always share information in a timely way and described how this affected their ability to carry out their work. They told us when information was requested to support their work, this information was not always provided.

However, we shared our findings with the registered managers who told us they had reviewed their information sharing policies to improve partnership working. Our experience during this assessment found the provider, registered managers and staff worked well with the inspection team to provide the information needed for the assessment and overall, they were responsive to our regulatory requests.

The provider did not always effectively focus on continuous learning, innovation and improvement across the organisation. We found similar concerns had been identified at this assessment that were identified at the previous assessment, specifically in relation to medicines management, care planning, risk management and the accuracy and completeness of records. At provider level, we were not assured effective learning had fully taken place from feedback at the previous assessments to drive all the necessary improvements to the quality and safety of the service.