Lifeways Community Care Limited (Leicestershire County)

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• 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 Inadequate. This meant people were not 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, including the management of medicines, safeguarding and safe and effective staffing.

This service scored 31 (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. Opportunities to learn lessons to ensure people’s safety and improve their care experience were missed.

People's complex health risks were not robustly managed, which left people at risk of increased significant harm. For example, the management of acute health needs such as diabetes, epilepsy, stoma care and enteral feeding tubes (PEG) was not robust or managed safely. Additionally, oversight of incidents and accidents was poor with no evidence these were acted on to make improvements. For example, incidents where people were distressed and inflicted harm on themselves or others were not supported by an effective oversight process.

Staff told us they were not supported through de-briefing processes. Care plans and records were not reviewed post incident to identify what could be done differently to meet people’s needs and mitigate risks. One staff member told us, “We complete incident forms in the location and send a picture to the management team. We don’t get told if they have received them or if there are any actions to take following an incident. No lessons learnt and paperwork isn’t updated. We have no direction” This meant there was not a thorough process to review incidents, learn from them, improve care and keep people safe.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care.

People who required support from staff with acute health conditions did not have clinical oversight in place. One person had a stoma and had not had this reviewed by a stoma nurse for a significant period of time to ensure that care and treatment remained appropriate and safe. Other people required support with epilepsy and diabetes, catheter care and support with an enteral feeding tube (PEG) they did not have up to date protocols in place to ensure staff had the correct guidance to manage these health needs safely. Some people had not had their health need assessed by a clinical health professional. Staff had not been trained or assessed as competent to manage health care tasks safely, in line with local and national guidance for the management of delegated health care tasks. We observed people not being supported in line with health professional advice and guidance such as not moving people regularly to support with muscle strength and not managing enteral tubes (PEG) effectively to prevent infection. Thismeant people were at risk of poor care and treatment which increased the risk of infection and deterioration, despite requests made by clinical teams as preventative measures.

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 always recognise when people, their relatives or staff raised safeguarding concerns and failed to take appropriate action to report, investigate and action feedback to protect people.

The provider’s systems and processes for safeguarding people from abuse and neglect were not used effectively. Although the provider had safeguarding and whistleblowing policies in place, Staff and the management team did not always follow them. For example, they did not report externally or act in a timely way to respond to potential safeguarding allegations they were made aware of by staff. This included staff concerns around insufficient commissioned support hours, neglect, allegations of harm from staff and incidents of physical harm to staff during periods of heightened distress.

Records relating to potential safeguarding incidents were not always available for reference and review at services to maintain effective oversight of incidents. Staff told us the registered manager took these records for analysis so there were times when this information was not available. Relatives raised concerns regarding the safety of their family members and lack of action taken by the management team. One relative told us, “I had a call from a whistleblower (staff member) who said they witnessed a member of staff shining a torch in my relative’s mouth to check if she was still alive. I tried to contact the House Manager to report it, but they did not come back to me. It was an immediate safeguarding concern.” This put people at risk of not being listened to when they raised concerns and at risk of abuse and neglect going undetected in the service with lack of robust and timely action being taken to protect people from harm.

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.

The provider’s systems and processes that assessed people’s individual risks in relation to their safety and wellbeing and the actions required to mitigate risks, were not sufficiently robust. For example, there was a lack of robust risk mitigation for people who presented with distressed behaviours and staff lacked knowledge and understanding of a positive behaviour support (PBS) methodology. Staff were unable to tell us what strategies were used to keep people safe though proactive, active and reactive approaches to support people in distress.

Ineffective systems impacted people who required oversight and support with managing risks related to acute health conditions. We reviewed care records and found risk mitigation plans were not in place for people who had significant risks regarding the management of epilepsy and diabetes. Staff could not tell us how they would reduce the risk for people or how they would manage a decline in people’s health conditions. One staff member said, “I haven’t had any training to manage this health need, I just do what the other staff showed me.”

Relatives raised significant concerns regarding the risk management presented by their family members. One relative told us, “The day service has made some safeguards regarding a choking hazard. [Person] was sent in with an apple. Why? They know the care plan and they didn't follow the eating plan”. Another relative said, “I expect robust systems in place. It was only when [person] deteriorated that we realised these systems to keep them safe are not in place.” This put people at risk of harm through receiving unsafe care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People’s homes were clean, tidy and well looked after. People had personalised bedrooms, communal areas and décor. However, people raised concerns with facilities and equipment available to them. One person said, “I fell out of bed, and it hurt. The mats by my bed are not in the right place” and “I did not like it when I had to use the small bathroom as I struggled to turn in it. Okay now, I am allowed to use the big bathroom but when another person lived here the manager said I was not allowed to use the big bathroom”. Some relatives also raised concerns with the environments their family members lived in. One relative told us, “Home is clean, bathroom is a wet room which has mould in there and they paint over. Chipped radiator in there too. The lounge looked like an institution”. Although some residences were homely, others required maintenance. The environment wasn’t always managed to meet person centred care.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

We viewed staff files across the residences. We found there was a lack of information and required recruitment documentation for some staff members. This included pre-employment checks such as references, interview records and work history. We requested the missing information from the registered manager; however, these were not shared with us.

We reviewed staffing rotas between 31 March 2025 and 30 April 2025. At some residences we found ineffective staff deployment and shortfalls in ensuring people received their commissioned hours. This meant people were left for significant periods of time without support to meet their personal care and emotional needs. One staff member told us, “The registered manager is using hours to provide 2-1 care for one person here, which means the other person goes without any support for long periods of time and has to wait for assistance outside of their 1-1 hours”

Training records provided by the registered manager identified significant short falls in in the providers mandatory training, such as moving and handling and repositioning people. This meant staff were using assessed lifting equipment for people without the required training and competencies to ensure this was carried out safely. Specific training for staff supporting people with individual health and social needs, such as, learning disability and autism, mental health, positive behaviour support and training required to manage acute health conditions including diabetes, epilepsy rescue medicine administration, catheter care, stoma care and enteral tube (PEG) training had not been delivered to staff teams working directly with people.

We reviewed the providers staff training records and found staff had not completed practical training in moving techniques and the use of equipment to support people to move safely. Staff told us they had not had the relevant training to ensure all care tasks were delivered safely. One staff member told us, “I have never been trained to complete this, though I have to show the new staff what to do, so they can do it when we are not here”. This meant the provider failed to ensure staff teams had the appropriate training, skills and competencies to deliver safe care. This put people were at risk of poor care and treatment and their assessed health and social needs were not managed safely.

Relatives raised concerns regarding staff training and deployment. One relative said, “They are not trained properly to look after anyone. Maybe basic first aid training. They don't know [Name].There is different staff, no consistency of staff.” Another relative told us, “[Name] is safe now, as there’s enough staff, but they’re not trained for peoples developing needs no. Turnover of staff are so high. I don’t think they are competent because they all have complex needs. It takes a while to get to know them. Know their likes and dislikes. They only would know that if they have worked there long enough”.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There was a lack of systems and processes to ensure clinical waste was disposed of efficiently and correctly to reduce the risk of infection. For example, staff lacked knowledge of the correct procedure to ensure colostomy bags were disposed of safely. One staff member told us, "I'm not sure if there is a process or a right or wrong way to dispose of this. This is what I was shown when I started". We also observed over filled sharps boxes, plastic containers provided by pharmacies to dispose of used needles, in 2 residences, one sharps box was split. This meant used needles or sharps could become loose from the enclosed safety box, increasing the risk of infection.

Staff were observed to wear personal protective equipment when providing personal care and stocks were available in residences if required.

The provider did not make sure that medicines and treatments were safe and met people’sneeds, capacities and preferences. People were not supported by staff who received adequatemedicines training and competency checks. Medicines were not always stored safely and wereaccessible to people, including those that lacked capacity to manage their own medicines. Wesaw that one person’s when required (PRN) medicine for distressed behaviours had beenexpired since 2023. This meant that this medicine would not be suitable if the person required it.When people were prescribed medicines for agitation, guidance and care plans lacked person-centred information to support staff in administering these medicines effectively. We saw thatmedicines administration records (MAR) were not always correct. For example, incorrect doseswere seen on two people’s records. One person’s MAR chart did not have the topical barriercream they required to reduce the risk of enteral tube (PEG) site infection recorded on theirMAR. Staff confirmed this had not been applied as it was not on the MAR. This meant that there was an increased risk of infection, impacting on the sustainability of the PEG tube. We escalated this immediately to staff. When people were prescribed paraffin-based creams, there was no information recorded, and staff were not aware of the fire risks associated with these. There was a lack of oversight from leaders around medicines related issues. Staff told us that incidents were not always investigated appropriately and lessons learned were not shared. Medicines audits were completed at each residence; however, they had not identified the concerns found on inspection.