Lifeways Community Care Limited (Norfolk)

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

Safe – 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 good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager promoted a proactive and positive culture of safety, based on openness and honesty. Accidents, incidents and safeguarding concerns were clearly recorded. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager told us, “Lessons learned are used to inform and shape our learning outcomes. I personally document any lessons learned—whether they relate to communication, environment, or other areas. When appropriate, I share these insights with the team via email. Team Leaders then cascade this information to their staff members. Since all staff have a Lifeways email, we can ensure information is shared effectively. We also make use of a team’s app to support this process.”

The registered manager collaborated with people and healthcare partners to establish and maintain safe systems of care, ensuring that safety was consistently managed and monitored.

They prioritised continuity of care, particularly during transitions between services. During our assessment, a transition to a more specialised service was managed sensitively and in close collaboration with external professionals, ensuring a seamless and safe pathway for the person involved.

The registered manager worked collaboratively with individuals and healthcare partners to understand what safety meant to each person and how best to support it. Staff focused on enhancing people’s lives while upholding their right to live safely, free from abuse, discrimination, and avoidable harm.

Safeguarding concerns were shared promptly with local authorities. However, not all required notifications had been submitted to the Care Quality Commission, the registered manager acknowledged this oversight and was now fully aware of the need to notify all relevant bodies going forward.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people's personal safety were assessed, monitored and managed effectively. The support plans contained detailed and person-centred information regarding how to make sure people were kept safe in all areas of their daily lives, such as nutrition, mobility, mental health, finances, activities and medication.

Staff knew people well; they were able to tell us about associated risks to people and how they managed those risks. Staff comments included, “Through regular routine support we promote positive risk taking where possible. We make sure we follow our users' choices and promote self-confidence” and “The [registered manager] sets up the support plan, and we support them to do the risk assessments, but they check this as well. Both [name] and [name] have ceiling hoists. [Name] is fully involved with their risk assessments, and we go over it with them, so they understand the assessment. [Name] lacks capacity so we do talk to them about it, but it is mainly their relative that is involved.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Everyone using the service lived in their own homes with individual tenancy agreements. Staff made sure these homes were clean, safe, and well looked after. Staff told us that any maintenance issues were recorded and passed on to the landlord. We saw some redecoration happening during our visit, and the registered manager informed us they were waiting for new carpets to be fitted in the communal corridors.

The provider ensured there were enough skilled and experienced staff who received regular training, supervision, and support. Staff worked well together to deliver safe, person-centred care.

Safe recruitment practices were followed, including DBS checks, references, and proof of ID, helping ensure staff were suitable for their roles.

People were supported by consistent staff who knew them well. Staff spoke positively about the training they received, covering a wide range of topics like safeguarding, medication, epilepsy, and positive behaviour support. One staff member told us, “I’ve completed lots of training, including fire safety, mental capacity, and dysphagia.” Another said, “The epilepsy refresher helped me feel confident in supporting people and advising colleagues.”

Staff felt there were enough team members to support people safely. One said, “We usually have six staff during the day, and people who need 1:1 support get it.” Another added, “We’re never left short-staffed—there’s always enough cover, including waking night and sleep-in staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff helped people maintain good hygiene and keep their homes clean. They confirmed they’d completed infection control training and had access to PPE when needed. The provider had clear systems in place to reduce infection risks, and we saw that any concerns were dealt with quickly.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely, on time and as prescribed. Policies and systems in place supported this. Medicines were stored securely in people's own flats. Medicine administration records were complete and no gaps in recording were identified. Where people had been prescribed 'as and when required' medicines, there were clear protocols in place giving guidance on how and when these medicines should be administered.

All staff responsible for administering medicines had received training followed by an observed competency assessment to ensure that they had the required skills and were competent to administer medicines. Daily, weekly and monthly medicine checks and audits were completed to ensure people received their medicines safely and as prescribed.

A relative told us, “All [names] medicines are on their MAR chart, staff seem to do it well and they know the importance of [name] having it.”