Lifeways Paragon Limited (North West)

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 is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance processes needed strengthening to ensure concerns were identified and lessons were learnt. Audits did not always pick up on concerns found during the assessment process and not all staff knew how to access the service’s policies and procedures.

Staff spoke highly of the registered manager and felt supported by the management team. People were actively encouraged to attend community groups to enhance their wellbeing.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff felt this service held good values. They said, “There is a good culture here and a friendly, warm atmosphere.” Staff told us they attended regular team meetings which they found helpful for finding out information. Staff were complimentary of the registered manager. They said, “The (registered) manager has been so supportive of me. I told them a few months ago I had too much going on and they resolved this for me. whenever I need them, they are around. They are very knowledgeable.” Another staff member said, “The managers and the service managers are very good. Anything you need they will help with. The (registered) manager goes above and beyond.”

The registered manager told us their goal was to ensure all the people they supported had the opportunity to choose where and whom they lived with and to create a personal and safe space for people. There was emphasis put on people’s choice and respecting people’s rights and preferences. There was an open culture where staff appeared relaxed around the management team. Regular spot checks were being carried out to ensure managers had oversight of their services.

Leaders did not always identify and act on concerns. Although there were a range of quality checks in place, these checks did not always identify the concerns found during this assessment process. Some audits had not been fully completed including the medicines audit which might have identified the concerns found in the management of medicines. Where issues were identified in the audits they did not always appear to be oversight or actions taken following these.

Staff told us the registered manager and other managers of this service were approachable and knowledgeable.

The service fostered a positive culture where people felt they could speak up and their voices would be heard. Staff knew the process for speaking up and told us they felt able to raise concerns should they need to. The registered manager told us they promoted an inclusive culture where every staff member felt valued, respected and encouraged to speak up.

People had tenancy agreements as part of their contract, however, there was a separation between the care provision and the tenancy agreement which meant people could still live at the service should they wish to change care provider. This empowered people’s rights.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were treated fairly and felt listened to by the registered manager who they could speak to should they have any concerns. Reasonable adjustments were in place including flexible working arrangements, adjusted working hours and extended breaks. Staff meetings were taking place regularly and staff feedback was sought. Where negative feedback was given, this was investigated and monitored by higher management.

The service did not always 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. There appeared to be a lack of oversight of medicines and risk management. The concerns found in relation to medicines were not identified through audits and the concerns in relation to choking risks had not been addressed in a timely manner, despite an incident of this nature occurring at the service. Support plans required updating to ensure accuracy and to guide staff on how best to care for people. Fire safety concerns had not always been addressed and concerns relating to the environment had not been actioned in a timely manner. People’s capacity had not always been appropriately assessed and there appeared to be a lack of oversight in this area.

Policies and procedures had not always been updated in the required timeframes, and we received conflicting information from staff about where they would access the service’s policies and procedures. This meant we couldn’t be assured staff had read them. The registered manager and provider acted on these concerns during the assessment process and were looking at strengthening their audit process.

Staff told us they knew the management team well and believed concerns relating to people’s care would be addressed in a timely manner.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Relatives told us people attended community groups in their local area. Staff were actively sourcing a community group for a person to attend to enhance this person’s quality of life. The registered manager told us they actively supported people to access community support groups to avoid social isolation and enhance people’s wellbeing.

Staff told us people were supported by advocates and social workers when needed. However, this was not always documented in people’s support plans.

The service did focus on continuous learning, innovation and improvement across the organisation and local system; however, we did not always see lessons learnt embedded. Where incidents had occurred, it was not always clear what action was taken to reduce future risks. We did however see good practice in this area where an incident occurred at one service and this was shared with other service managers to discuss and avoid recurrence.

Staff told us how information was shared. They said, “We discuss lessons learnt at team meetings, we also have an app (electronic system) which we can look at the latest news and find any information out.” The registered manager encouraged staff to develop their skills and knowledge through various initiatives and champion schemes. Staff were encouraged to pursue professional development opportunities such as certifications, workshops and courses.