Lifeways Community Care Limited (Leicestershire County)

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

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 Inadequate. This meant there were widespread and 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 25 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a closed culture across the service. Staff were not reporting concerns in line with the providers whistleblowing policy. The registered manager was undertaking historic investigations with staff who have been reported for poor practice. Staff teams were not cohesively working together or promoting a positive culture in line with the provider’s vision and values.

The registered manager told us “We are in a process of a culture where staff are holding onto concerns until it suits them to report them. Staff are coming forward at later dates when it suits them to report other staff for poor practice or allegations of abuse” This demonstrated a lack of collaborative culture, where staff felt listed to and communicated with.

There was also a racist culture amongst staff teams, causing friction and a divide between staffing teams working directly with people. The registered manager told us, “There is a racist culture amongst staff and some relatives. I have had lots of racially motivated complaints.” We viewed incident forms in people’s residences. On 2 April 2025 a staff member had received racist remarks from other staff teams. At the time of this inspection the provider had not taken any actions to ensure the culture of the service was inclusive, empowering and staff had an understanding of equality and diversity. Leaders and managers failed to promote equality for staff and tackle discrimination.

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

We found leaders were not knowledgeable about issues and priorities to ensure a quality service was provided. There was limited independent scrutiny of the service and support was neither requested nor provided. Leaders were not alert to examples of poor culture that affected the quality of people’s care and have a detrimental impact on staff.

Some staff told us there was a lack of leadership, oversight and guidance from the management team. One staff member said, “My main concern is that we don't get support when we need it here. We don't get the paperwork, we're not updated, there's lack of communication between managers and staff. Just nothing seems to be shared with us. I think the whole time i have been here, I've only met the registered manager once”.

Relatives also raised concerns with the leadership of the service. One relative said, “There’s not much communication. The House Manager is not in contact. I told them they were inept and is quick to blame others. They walked out of one meeting we attended”. Another relative told us, “When we ring the manager of a weekend to raise concerns, the registered manager says, yes, we will investigate. They never do”

We raised concerns with the senior leadership team regarding the lack of knowledge and understanding the management team had about the people cared for under their registration, including the feedback from staff and relatives.

We received some immediate short term and longer-term assurances from the higher management in response to our concerns. For example, staff training had been reviewed and identified training needs had been arranged with relevant staff teams.

People did not feel they could speak up and that their voice would be heard.

The provider had policies in place to ensure staff teams had guidance when raising concerns, however, people and relatives confirmed they had raised concerns with the registered manager in the past, however, they felt these had not been listened to. The registered manager confirmed there was a closed culture in the service which had been raised by staff teams. The registered manager told us, “We are addressing this in team meetings and have work chats on the workplace system, which staff can use to raise concerns. We have also shared the whistleblowing policy again with staff” However, Staff were not confident their concerns were listened to and acted on to make improvements. Staff provided examples of concerns they had raised in relation to people’s care and support and issues around poor cultures but felt there had been no changes or improvements as a result and had not received any response to their concerns.

Staff told us they were able to voice their opinions and make suggestions in staff meetings and supervisions and directly with the service managers, however, some staff felt actions were not taken, particularly regarding risk and essential training. Staff had raised concerns regarding their lack of training to use manual handling equipment. Although staff raised this risk with the registered manager, it had not been acted on. One staff member said, “I haven't reported staff members, but I have reported things regarding the people we support. I don't feel like they listen though, nothing ever changes here”.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had a choice recognition reward scheme in place to motivate and support staffing teams.

There was an evolving racist culture amongst staff teams. The registered manager told us, “The staff team has become more multi-cultural which has caused a staff divide across the service due to differing cultures”. The registered manager told us they were in the process of sourcing some training for all staff to attend. However, this had not been sourced at the time of this inspection.

Relatives also raised concerns regarding the culture of staffing teams working directly with their family members. One relative told us, “It is obvious the staff are caring, and I don’t doubt they work to the best of their ability. The big issue is the management. Staff falling out with each other, with allegations and so on. Unfortunately, staff are either let go or leave.” This demonstrated leaders had not taken action to prevent or address bullying and harassment of staff or respect the diversity of the staff team.

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.

Systems and processes to monitor and ensure incidents were managed and acted upon to keep people safe were not robust. Lack of effective oversight and leadership from the management team meant we found shortfalls and inconsistencies across the service which monitored safe service delivery, staff performance and improvement to keep people safe from poor care and treatment.

We found a lack of effective oversight meant people who were at risk of harm of not having their needs responded to, reported or actions taken to keep them safe. The absence of effective monitoring systems including the electronic auditing system (RADAR) in relation to incidents meant the service failed to identity the poor quality of reporting and missed opportunities to properly investigate, learn lessons, review people’s care plans and prevent re-occurrence. This meant the management team did not have a full oversight of all incidents that occur within the service. We cannot be assured each incident was managed safely and reported effectively tokeep service users safe.

Staff told us they were left to manage their services on their own and had no guidance in how to support people safely when things go wrong. The registered manager told us, “There is no formal process to ensure oversight of incidents and regular service checks by the service managers, I admit there is a gap between the services and me, there is no accountability and staff oversight”. This meant relevant and significant information regarding people and safeguarding incidents were not always shared with the management team and could lead to a risk of recurrent incidents and/or service users not being protected from harm.

The providers tiered governance systems and processes had not been embedded across the service to ensure it was robust or effective. Service managers had not identified the shortfalls found at this inspection to alert the registered manager of actions needed to improve the quality of the service or ensure people remained safe. The registered managers oversight within the tiered governance process was not robustly managed. We were not assured actions were taken in a timely manner. We found missed opportunities to improve the quality of care and treatment for people living in the service.

Relatives also raised concerns with regard to the management of the service and the lack of oversight and leadership. One relative told us “The manager doesn't spend enough time there to see what the staff are doing”. The model of care was not in line with right support, right care, right culture. This is because the governance framework within the service was unclear, there was a closed culture within the staff team and the registered manager was not always visible and did not demonstrate commitment to improving standards of care for people.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Staff in some residences worked closely with external agencies and the local community to ensure people could access the services they needed, However, external partner agencies responsible for commissioning services and safeguarding people raised concerns with the lack of response, development, communication and engagement from the registered manager when things went wrong to ensure swift investigation and response.

The provider did not focus on continuous learning, innovation and improvement across the local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Although the registered manager shared innovative practices and organisational developments across the wider organisation including Values in Action, we found this was not embedded in local practice. For example, the 5-tiered governance system had not been embedded locally to ensure the registered manager had effective oversight of the quality of service delivered and closed cultures and racist cultures that had developed within the service locally had not been responded to by the registered manager or higher management despite this being known.

Staff meeting minutes were viewed between January 2025 and April 2025. Service managers had recorded conversations with staff teams regarding conflict and recommendations to report ongoing concerns to management where required. However, At the time of the inspection there had been no actions taken to learn lessons and tackle staff practice or cultures cross the service.