Lifeline Agency 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 in breach of legal regulation in relation to the governance of the service and not notifying CQC of allegations of abuse, as part of their registration regulation. Governance procedures were not always effective. The provider had not identified all the quality, or risk concerns we found during our inspection. This meant prompt action had not been taken to address shortfalls.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and their relatives were happy with the service and management. Comments from people included, “Everyone is very supportive in the office,” and “I’m most pleased with the service.” One relative told us, “The managers are very helpful and have often come to have a chat. Everyone makes them smile. I’ve not had a bad experience at all.”

Staff felt supported by management in their role. One staff member told us, “The work environment is always positive. Everyone gets along well, and we support each other. Managers are kind and fair, and we’re recognised for our hard work.” Another staff member said, “I feel supported. The management is always there for the team, and they are willing to listen and support us.” Other comments included, “It is a good place. I enjoy helping people and making a difference in their lives.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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. The provider lacked understanding of their regulatory requirements and responsibilities. The provider had failed to notify us of abuse notifications as part of the requirements of their registration.

The provider failed to identify the issues we identified at this inspection including but not limited to, care planning and risk management. The providers audits were not robust and failed to drive improvement. Sometimes the audits contained incorrect information.

Records showed staff were late to some calls and did not always have time to provide people’s full allocated call time. One staff member told us, “Sometimes travel time between clients is tight, especially during peak hours. This can lead to us being late, but we’re encouraged to call the office if we’re running behind. I try to stay the full allocated time, but occasionally I have to shorten a visit to stay on schedule. It’s not ideal, and I’ve raised this in team meetings.”

At the last inspection we raised concerns with the provider about people’s daily care notes as we were not assured staff were always using respectful language and terminology due to language barriers and poor spelling. We relayed our concerns to the registered manager, and they agreed to review these regularly and act as needed to support staff to use appropriate language when recording care delivery. However, we found the same concerns during this inspection. At the last inspection we also raised concerns about people’s likes and dislikes for food not being explored to improve people’s care. During this inspection we found that this had still not been explored with people.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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. The registered manager was open to our feedback during the inspection and had arranged to improve training and practice for diabetes and fire risk assessments.

We were concerned that some of the concerns found at this inspection had been identified during the last inspection and improvements had not been made in these areas. This meant that learning has not been embedded to drive improvements to the service.