Lifeways Community Care Limited (Leicestershire County)

On this page

• 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. At our last inspection rating inspection, we rated this key question Inadequate. At this inspection the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of the legal regulations in relation to people’s safe care and treatment, and for 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 always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service did not demonstrate a learning culture which supported continuous improvement. Staff reported limited opportunities for reflective practice, and there was no structured or reliable process for learning from incidents, complaints, or near misses. Incidents had occurred repeatedly, yet there was no evidence leaders had analysed these or taken effective action to prevent them happening again. Communication within the service was ineffective, and important information was not consistently reported to the registered manager, resulting in missed opportunities to identify patterns, address risks, and drive improvement. Lessons that were identified were not shared across the team, meaning the same issues continued to recur and people remained exposed to avoidable harm. Leaders did not foster an environment where staff felt confident to question practice or contribute ideas for improvement, and learning was not embedded into policies or day‑to‑day care. This meant the service could not be assured that it was improving the quality and safety of care.

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

Safe systems, pathways and transitions in this supported living service were not effectively established or implemented. Staff did not have clear or consistent guidance to follow when coordinating people’s support, and essential information was often missing from risk assessments and daily records. For example, when people required staff to effectively monitor health‑need presentations, we found consistent gaps in recording and insufficient information to support safe and timely decision‑making. People experienced poorly managed transitions between services, with delays in sharing updates and no reliable process to ensure all relevant staff were informed. This resulted in disjointed support and increased risk, particularly for individuals with complex support needs. Leaders had not reviewed or strengthened systems despite repeated issues in handovers, care coordination and health monitoring. The service could not be assured people were supported safely throughout their care journey.

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 share concerns quickly and appropriately.

Our review of the provider’s IT governance system audits completed between October 2025 and January 2026 identified significant weaknesses which directly compromised the leadership team’s ability to safeguard people. Safeguarding concerns were not reliably captured, tracked, or escalated, leaving leaders without an accurate understanding of emerging risks.

We found examples where safeguarding issues had been signed off without sufficient scrutiny, only for the same concerns to re‑emerge due to a lack of effective follow‑up and assurance. This included repeated incidents of one person leaving their home without the assessed support in place to keep them safe (absconding). January 2026 audit records referenced an incident where a person left the garden area and went to a local shop, leaving the person without essential supervision. Despite this, the person was able to leave the property again later that month by identifying a second gate that did not have a sensor fitted and exiting through this point. This demonstrated risks were not fully assessed or mitigated, and lessons from the first incident had not been embedded into practice. Furthermore, partner agencies were not informed of the incident, representing a failure to meet statutory safeguarding reporting requirements and evidencing a lack of managerial oversight of significant safety concerns. These failings showed a systemic inability to recognise, respond to, and learn from incidents which may indicate harm, leaving people at continued risk of avoidable injury.

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 service did not have effective systems in place to assess, manage or mitigate risks, and this placed people at significant risk of harm. Risk assessments were inconsistent, lacked detail and were not routinely reviewed effectively, meaning they did not provide staff with the information needed to support people safely.

People with complex needs and acute health conditions were particularly at risk of poor care. For example, people with a diagnosis of epilepsy, diabetes, and those with complexities around eating and drinking safely did not have personalised, detailed or up‑to‑date risk plans which guided staff on how to support them safely.

We reviewed the records of people who had experienced epilepsy seizures and found serious and unsafe shortfalls in how risks were assessed, monitored and responded to. Care plans did not consistently describe the type, pattern or presentation of seizures, and staff did not comprehensively document the nature of seizures when they occurred. This meant important clinical information was not available to guide safe decision‑making.

As a result, staff did not have the information required to recognise deterioration, respond appropriately to emergency life threatening situations, or make timely decisions to protect people from harm. These failings meant risks were not effectively managed, and people were exposed to avoidable and ongoing safety concerns.

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

The environment was not consistently safe or well maintained, and improvements were needed to ensure it supported people’s health, safety and wellbeing. Systems to monitor the safety of equipment and the environment were not always effective, and checks were not completed reliably. We found contradictions within the provider’s tiered auditing processes, which meant issues were not identified or acted upon in a timely way. For example, a person slept on a compromised mattress for 10 days before this was replaced, increasing the risk of discomfort, skin breakdown and reduced quality of sleep.

Environmental risk assessments were in place but were not always updated when changes occurred, and actions identified to reduce risks were not consistently completed. Staff did not always have clear guidance on how to maintain a safe environment or escalate concerns promptly. These shortfalls meant the environment did not fully support safe care, although we did not find evidence of immediate or serious harm.

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 found gaps in essential training, supervision and competency assessments, meaning staff were not equipped to recognise risks, respond to health concerns or deliver safe support. For example, people who required staff trained in epilepsy management and the administration of rescue medicines to prevent status epilepticus were supported by staff teams who were not trained or assessed as competent to administer this life‑saving medicine. This meant staff would not have been able to act quickly or appropriately in an emergency, placing people at immediate risk of serious harm.

Staff were recruited safely including relevant pre-employment checks. Some improvements had been made with the overall staff training compliance. However, staffing arrangements at some locations were unsafe and ineffective, which exposed people to significant and avoidable harm. While some locations deployed staff in line with people’s assessed needs, others failed to ensure sufficient numbers of suitably skilled staff were available. Additionally, at some locations, people’s 1:1 support hours were inappropriately pooled to facilitate group outings instead of being used to meet their individually assessed needs, further compromising their safety and autonomy.

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.

People’s homes were clean, tidy and well maintained. People had decorated their homes with personal preferences. Where required, equipment to support people to move had been serviced and some properties had been adapted to meet people’s needs. Although we observed staff wearing PPE (Personal Protective Equipment) when needed and noted appropriate PPE stocks were available in people’s homes, these strengths were undermined by inconsistent practice and limited oversight.

There were gaps in the provider’s tiered auditing systems, which meant staff were not consistently completing the relevant checks required to maintain safe infection prevention and control practices. Audits lacked depth, were not carried out reliably, and did not provide the oversight needed to identify shortfalls or drive meaningful improvement. As a result, important IPC tasks were missed or completed inconsistently, and the provider did not have effective assurance safe standards were always being met across the service.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Not all staff had received training or competency assessment in administering emergency rescue medicines. In several records completed by clinical professionals there were clear instructions epilepsy rescue medicine should have been administered in line with the person’s ‘as needed’ (PRN) protocol available to staff. However, this had not been administered when people presented with seizure activity within the scope of requiring their rescue medicine. This placed people at immediate and significant risk of developing status epilepticus, a life‑threatening medical emergency.

People did not always receive their medicines as prescribed or intended. For one person with swallowing difficulties, records showed their medicines should have been crushed or provided in liquid form to reduce the risk of choking and aspiration pneumonia. However, staff told us they did not administer medicines in this way. In addition, the person’s care plan stated medicines were being given covertly, disguised in food or drink. There was no Mental Capacity Act assessment or best interest decision to authorise this practice, meaning medicines were being administered without the required legal safeguards. This represented a serious breach of people’s rights and placed them at increased risk of harm.