Lifeways Community Care Leicester (West)

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

This means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant people were not always safe and were at risk of avoidable harm.The service was in breach of legal regulation in relation to people’s safe care and treatment, and safe and effective staffing.

This service scored 47 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was insufficient evidence of organisational learning from incidents, and a lack of transparency in how safety concerns were addressed. Systems and processes to assess, monitor, identify and mitigate risks to ensure the health and welfare of people using the service, staff and others were not robust or effective. A lack of effective oversight meant people who were at risk and in need of intervention had not had their needs responded to, reported or actions taken to keep people safe. We found repeated incidents of similar nature including incidents of distressed behaviours which resulted in harm to people and staff teams. This demonstrated that lessons were not being learned or applied.

The providers RADAR system (electronic incident log) had not been updated timely with incidents that occurred throughout August 2025. We also found recording gaps within incident forms completed by staff and team leaders. This meant the registered manager did not have oversight of potential safeguarding concerns to ensure incidents were learnt from or actions taken to protect people from further harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People did not always experience well-coordinated transitions between health and social care services. A relative told us they were not included in a transition plan, “When [person] moved into the accommodation with Lifeways, we weren’t really involved in the process or the planning of care”. Additionally, care plans had not been fully developed within the new electronic care planning system. This meant contradicting information had been recorded within people's care records or relevant and important information was missing to ensure staff could support people safely. We found care records had not consistently been updated following significant incidents of distress or changes in assessed need, which led to delays in proactive support and confusion among staff.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Representatives told us they felt their relatives were safe. Comments included “I have never had to raise a safeguarding concern. [person] is safe and has a little flat which is secure”

Safeguarding systems and processes were ineffective, and there was a concerning lack of incident management and oversight. Staff had received relevant safeguarding training and understood their responsibilities to report safeguarding concerns; however, some management teams were unclear about what constituted a safeguarding concern and lacked confidence in escalating issues. Several incidents including distressed behaviours where people came to harm, were not reported to the local authority or investigated internally. There was no evidence of learning from safeguarding events, and no structured approach to identifying patterns or risks. People supported were placed at risk due to poor oversight, inadequate staff training, and a failure to act on concerns raised by staff teams and partner organisations.

Although individuals had current Deprivation of Liberty Safeguards (DoLS) authorisations in place, the registered manager failed to ensure that all restrictions applied to people were appropriately authorised and reflected within the DoLS documentation. This oversight meant that some restrictive practices such as lap belts used in wheelchairs were implemented without legal justification or proper safeguards.

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

People who required support with distressed behaviours had not had a skilled and qualified person complete a professional review of their assessed needs or the functions of their behaviours. As a result, staff were not equipped with proportionate, least restrictive, or appropriate approaches to reduce incidents and keep people safe. There was a significant absence of person-centred positive behaviour support and risk mitigation strategies, and staff were not provided with sufficient guidance or training to respond safely and consistently when people became distressed. This led to unsafe practices and increased the likelihood of avoidable harm.

There were significant concerns around moving and handling practices, where poor risk mitigation and a lack of clear guidance placed people at risk of harm. Observations of staff practice revealed unsafe techniques and inconsistent approaches, with no evidence of oversight or corrective action.

The provider did not embed the principles of Right Support, Right Care, Right Culture, because they failed to promote a learning culture where incidents were reviewed and support adapted to reduce future risks. As a result, people were placed at continued risk in an environment that did not prioritise their safety, dignity, or independence.

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. People lived in their individual flats and where required staff supported people to maintain their tenancies with the landlord of the property. People were supported to decorate their own accommodation and personalise their individual spaces to meet their interests. Within the building there was communal spaces where people gathered for meals, activities or celebrations. However, the supported living environment did not consistently reflect the principles of Right Support, Right Care, Right Culture. Physical communal spaces were not always adapted to meet the sensory, mobility, or communication needs of people with learning disabilities and autistic people. For example, there was a lack of proactive planning to ensure people could safely access joint planned activities. Overstimulating, loud and busy communal areas were observed which at times escalated distress. These issues compromised people's safety and autonomy, improvements were reactive rather than person-centred.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff were recruited safely, with appropriate checks carried out to ensure they were suitable to work with people who may be vulnerable. Staff confirmed they received regular supervisions. We reviewed the rotas for people between August and September 2025. Rotas were based on peoples individual commissioned hours and staff were deployed across the property to ensure people received their support.

Staff told us and training records confirmed moving and handling training was delivered primarily online and was not sufficient to ensure safe practice. Staff had not had their competency assessed for all manual handling care tasks, such as assisting with transfers, support a person from sitting to standing, or using hoists to help people up from the floor and other equipment. We observed poor manual handling practices that placed both staff and people at risk of injury.

Staff were not consistently equipped with the skills, knowledge, or support needed to deliver safe and effective care. Training was not always sufficient or up to date, particularly in key areas such as positive behaviour support, and communication strategies tailored to individuals. This meant staff were not always confident or competent in managing distressed behaviours safely and sensitively, which increased the risk of harm and impacted the quality of care. These shortfalls undermined the principles of Right Support, Right Care, Right Culture, and contributed to variable care quality and increased risk of harm for people.

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.

Staff followed clear protocols for hygiene, cleaning, and use of personal protective equipment (PPE), and these were consistently applied across the service. The environment was clean, well-maintained, and adapted to reduce infection risks while respecting people’s preferences and routines.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Records were kept of medicines prescribed for and given to people. Together with records of stock control they showed that people who used the service received their medicines at the times that they needed them. Any handwritten additions to printed medicines records were signed and checked by a second member of staff, in line with best practice and the home’s policy. Medicines were accurately reconciled and recorded when people enter the service. Administration was recorded accurately with checks in place to ensure records were completed.

Staff ensured there was effective communication with the prescriber and pharmacy about people’s medicines. Medicines were ordered in a timely way and were checked when they arrived. There was a good relationship with the pharmacy for support and advice.

Medicines’ care plans were up to date with information about how to support people with them including how people liked to take their medicines and any they were allergic to. Care plans included information on when to give emergency medicines for seizures.

People (or those acting on their behalf) were involved in assessing risks with medicines and supported to be as independent as possible.

When people had been prescribed medicines to be given on a ‘when required’ basis for most people detailed person specific care plans were in place to support people to have their medicines in a clear and consistent way.

External medicines, such as creams, were applied and recorded correctly. The use of body maps supported staff to do this safely, showing where to apply the creams.

Medicines were stored securely in people’s flats, at the correct temperature and within their expiry date. Medicines were disposed of safely and were returned to the pharmacy when no longer required. Medicines stored in people’s flats had been risk assessed to prevent inappropriate access.

Staff supported people to work with healthcare professionals, so their medicines were reviewed. Staff received medicines training and were assessed as competent to provide medicines support. There were clear policies and procedures describing how medicines were to be managed in the home.

Medicine incidents were recorded, analysed and learnt from. There was a good safety culture that encouraged staff to report these.

People with a learning disability and autistic people were supported following STOMP (stopping overmedication of people with a learning disability, autism or both).

There was good oversight of medicines. Weekly and monthly medicine audits were available and had been completed.