Lifeways Community Care Leicester (West)

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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

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 is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant there were 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 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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff told us there had been recent changes in management and changes in leadership within the service which had led to a better more inclusive culture. Relatives also confirmed recent management changes had led to some improvements. One relative told us “I think the staff are better, they seem to have the right ethos”. However, the service lacked a consistently shared direction and culture across the organisation. While senior leaders expressed a commitment to person-centred values and proactive care, this was not effectively embedded throughout the staff team. There was limited evidence that the principles of Right Support, Right Care, Right Culture were actively promoted or understood by all staff. The absence of a clear, unified vision led to inconsistent practices and a lack of accountability in delivering high-quality, inclusive care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff spoke highly of the management team and the changes made across the leadership of the service. Comments include, “The management changes have really made a difference. There are more planned social events now, such as BBQ’s and movie nights.” And “The managers are approachable. I feel I can raise concerns if I need to”.

However, the service lacked consistently capable and compassionate leadership, which hindered its ability to deliver high-quality, person-centred care in line with the principles of Right Care, Right Support, Right Culture. There was insufficient oversight of day-to-day operations, and leaders did not always take timely or effective action in response to concerns raised by staff. This led to unresolved issues around safe care quality, staffing, and training, and contributed to a culture where poor practice could persist.

People did not always feel they could speak up and that their voice would be heard. The service had processes in place to support staff in raising concerns, including whistleblowing procedures and access to senior leaders. While staff reported feeling able to raise concerns, they did not always feel listened to, and there was limited evidence that their feedback led to meaningful action or improvement. One staff member told us, “I have raised concerns with the lack of training when working with people who can be challenging. I didn’t get any training to support [person], I was just removed from working directly with them.” Systems for reporting concerns were in place, but they were not used effectively to promote transparency, learning, or accountability.

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. The service promoted workforce equality, diversity and inclusion effectively. It had a diverse staff team that reflected a range of backgrounds, cultures and experiences, and this diversity was valued and celebrated across the organisation. Leaders fostered an inclusive working environment where staff felt respected, supported and empowered to contribute and share their culture with other staff teams and people living at the service. For example, one staff member was supported to meet their cultural and religious needs throughout their shifts. A space was provided for staff members to use to complete their prayers throughout the day. Where possible staff were matched with tenants to meet people’s communication and language needs, and cultural celebrations and meals were prepared for and shared among all people living at the service. One relative told us, “[Person] has a very good carer three times a week. The carer is also Hindu and understands their cultural needs. If they ever leave, I’d really like another Hindu carer for [person] it’s been very helpful and so important for us”

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.

Governance and management arrangements were not effective in ensuring safe, high-quality, and sustainable care. There was a lack of clear processes to monitor service performance, report and respond to incidents, and manage safeguarding concerns. The service operated with multiple layers of management, but these did not function cohesively.

The RADAR system, intended to support incident reporting and governance oversight, was not used effectively and failed to provide accurate or timely information to drive improvement, resulting in repeated failures to identify risks, learn from events, or take timely action to keep people safe. Records were inconsistently maintained, with poor quality of recording across care documentation, incident reports, and ABC records (tools used to record and learn from distressed behaviours), making it difficult to track actions or evaluate outcomes. These failings placed people at risk of harm and undermined transparency and improvement.

Tiered governance systems were ineffective, lacked detail with poor communication and unclear accountability between operational and senior leadership. Despite the recent development of guidance for team leaders and management teams in the use of the tiered governance system, roles and responsibilities across the management structure were not clearly defined or understood, leading to confusion, inconsistent decision-making, and gaps in oversight.

The provider did not always understand their duty to 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. Staff teams had developed some links with local organisations and services such as day services and local entertainment groups designed for people with learning disabilities and autistic people. There was limited evidence of proactive engagement with community groups or networks to support inclusion and access to wider opportunities. Staff were not always supported to build meaningful external relationships, and the service did not routinely seek input from families or community stakeholders when shaping care delivery. As a result, people using the service missed opportunities to connect with their communities, and benefit from coordinated, person-led support. This approach does not fully reflect the principles of Right Support, Right Care, Right Culture, which emphasise collaboration, inclusion, and enabling people to lead fulfilling lives to ensure care is shaped through meaningful engagement and community connection.

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.

Stakeholders, including people using the service, families, and professionals, were not meaningfully involved in shaping improvement priorities or evaluating progress. One relative told us, “Communication is lacking. They used to send out questionnaires every year for us to feed our thoughts and ideas into to help improve the service. We haven’t had those for a while now”

Systems to review incidents, gather feedback, and evaluate performance were underdeveloped and not used effectively to drive meaningful change. Lessons from safeguarding concerns, and audits were not routinely analysed or shared, and actions taken lacked measurable impact. Organisational developments and shared learning were not effectively implemented at the local service level. The registered manager told us they had improvement plans in place with the local authority. We requested these action plans to review improvement and sustainability; these were not provided at the time of the assessment.