Lifeways Community Care Limited (Leicestershire County)

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• 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. At our last rated inspection, we rated this key question Inadequate. At this inspection the rating has remained 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 the legal regulation in relation to Good Governance

This service scored 36 (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 establish or embed a clear and shared vision, strategy or culture across the local service. Leaders did not promote or model values based on transparency, equity, equality, human rights, diversity and inclusion. These principles were not consistently understood, communicated or demonstrated in practice at this location. As a result, staff did not have a unified direction or a culture that supported openness, accountability or person‑centred care.

The service lacked a shared direction, and there is no clear or consistent vision guiding staff in delivering safe or effective care for all people using the service. Leaders at all levels did not provide adequate oversight, and staff reported feeling unsupported at times, including with the use of systems and processes that are essential for delivering safe and consistent care.

Some staff reported some improvements had been made with the culture of the service since the last inspection, including a change in registered manager, however these improvements were not embedded across all locations and had not resulted in a cohesive or positive culture across the service. The culture remained fragmented and reactive, with poor communication between teams and limited evidence of learning from incidents or feedback. This has resulted in inconsistent practice and a working environment where people’s safety and dignity are not always reliably prioritised.

Staff described a culture where issues were overlooked rather than proactively addressed, contributing to ongoing risks and a failure to drive meaningful improvement.

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.

Leadership was not capable, compassionate or inclusive, and the service did not benefit from consistent or effective managerial oversight. There was a clear disparity in the experience, knowledge and competencies of managers, which resulted in inconsistent standards of practice and variable expectations across different locations.

Some managers lacked the skills and confidence to identify emerging risks, challenge poor practice or provide meaningful support to staff, undermining the development of a safe and positive culture.

Staff and relatives commented positively on the new registered manager, noting improved communication and better service delivery at some locations following the last inspection. However, these improvements were not embedded across the whole service due to the inconsistent capability of the wider leadership team. As a result, the service lacked stable, skilled and cohesive leadership, and opportunities to strengthen practice and improve outcomes for people were repeatedly missed.

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

Although systems were in place for people and staff to raise concerns, these were not consistently effective in promoting an open and transparent culture. Several staff told us they did not always feel confident to speak up, particularly when concerns related to the performance or decisions of more experienced colleagues or managers.

There was limited evidence that learning from concerns was shared across the service, and some staff felt issues they raised were not acted upon in a timely or meaningful way. While leaders had taken steps to improve communication and encourage openness, these actions had not yet resulted in a consistently safe or supportive environment where all staff felt empowered to raise concerns without fear of negative consequences. As a result, opportunities to identify risks early and improve the quality and safety of care were sometimes missed.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although the provider had policies in place to promote fair and inclusive practice, these were not consistently embedded across the workforce. Staff told us that experiences of support, development and inclusion varied between locations, and some felt that opportunities for progression were not always applied transparently or equitably. One staff member told us, “There seems to be more opportunities for others that have been here longer or have a better relationship with the service manager than others do”.

While some staff described positive working relationships and felt respected within their teams, others reported that differences in background, identity or experience were not always acknowledged or understood. The provider had begun to take steps to strengthen its approach, but these actions had not yet resulted in

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.

We reviewed the provider’s tiered governance system audits completed between October 2025 and January 2026 and found governance arrangements were inadequate, failing to ensure safe or effective oversight of the service. Ineffective systems and processes meant relevant and significant information affecting people’s care and treatment was not consistently escalated or shared with the registered manager. This prevented appropriate and timely action being taken to protect people from potential further harm.

Gaps in governance systems, including weaknesses within the oversight of the tiered governance structure, meant important issues were not reliably captured, reviewed, or escalated through the appropriate channels, leaving leaders with limited visibility of emerging risks. Additionally, we found concerns previously signed off by service managers in earlier months were later highlighted again by the registered manager, demonstrating issues had been closed without being fully addressed or resolved. This reflected a lack of robust scrutiny and ineffective quality assurance at all levels. As a result, risks remained unidentified, unmonitored, and unaddressed, and opportunities to improve safety and quality were repeatedly missed, leaving people exposed to avoidable harm.

Following the 2025 inspection, the Care Quality Commission took urgent enforcement action and imposed conditions on the provider due to significant risks to people’s safety and wellbeing. At this inspection, we found the provider had not made sufficient or sustained progress to address these concerns. Despite the time elapsed and continued regulatory oversight, several of the same risks and systemic failings remained.

We continued to identify ineffective governance arrangements, poor oversight and management of risk, repeated failures to learn from incidents, and a lack of assurance that actions taken had led to meaningful or sustained improvement. These ongoing shortfalls demonstrate the provider had not responded effectively to previous enforcement action and did not have the leadership capacity or robust governance systems required to drive and maintain improvement.

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

The provider failed to work effectively in partnership with external organisations, which significantly limited its ability to improve service delivery and outcomes. Despite clear expectations and repeated direction from the commissioning authority, the provider did not take the necessary action to meet agreed improvement requirements over the past year. This lack of collaborative working meant known risks were not addressed in a timely or coordinated way, resulting in continued shortfalls in quality, safety and governance.

Feedback from community health teams highlighted ongoing concerns staff were not following the clinical guidance provided to them, leading to inconsistent and, at times, unsafe care practices. Health professionals reported important information they shared was frequently lost, overlooked, or not incorporated into care planning in a timely manner. At some locations, this continued to occur despite regular reminders and updates within team meetings from service managers, who had emphasised the importance of adhering to external guidance and embedding professional advice into daily practice.

The lack of effective communication and follow‑through meant people did not benefit from coordinated, multidisciplinary input, and risks were not managed robustly. Links with the wider community remained weak, with little evidence of proactive collaboration to enhance people’s wellbeing. As a result, some locations failed to utilise the expertise and resources available, and people experienced fragmented, poorly coordinated care.

The provider did not embed a culture of effective continuous learning, innovation and improvement across the services under this registered location.

The provider did not demonstrate a culture of continuous learning, improvement or innovation across this local system. There was no clear focus on developing or embedding new approaches to improve people’s experiences, outcomes or quality of life, and staff were not encouraged to explore creative or evidence‑based ways of delivering more equitable support.

Although senior leaders had developed improvement plans following the previous inspection, we found limited evidence of meaningful progress, particularly for people with complex health and social needs. Oversight of these development plans had not resulted in tangible improvements or better outcomes that directly impacted people’s day‑to‑day experiences.

The service did not actively contribute to sector learning, safe and effective practice, or research that could enhance care for people using the service, meaning opportunities to drive improvement and adopt innovative practice were missed.