Lifeways Community Care Ltd (Leicester)

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 rated inspection we rated this key question requires improvement. At this inspection the rating has changed to 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 34 (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.

Management oversight was ineffective and inconsistently applied. Leaders did not ensure incidents were thoroughly reviewed, investigated, appropriately closed, or used as opportunities for learning and service improvement. Systems and governance processes were not used effectively to monitor incidents, identify themes and trends, or provide assurance that actions had been completed and risks reduced.

For example, a safeguarding incident had not been reviewed, learning had not been identified or embedded into practice, and the incident had not been formally signed off by leaders. In addition, records showed that 12 incidents which occurred at one location during July 2026 had not been signed off within the provider's incident management system. This meant there was no evidence management had reviewed the incidents, assured themselves that appropriate actions had been taken, or confirmed that learning and service improvements had been implemented.

As a result, opportunities to learn from incidents were missed, actions were not consistently followed through to completion, and leaders could not demonstrate that risks had been effectively mitigated or that the likelihood of reoccurrence had been reduced.

A manager told us, “In terms of learning outcomes and review of incidents that’s the piece we need to strengthen. Before, our understanding was there were definite gaps, now we need to go full circle and how this goes back into the service to ensure lessons are learnt.”

The provider did not always work well with people and healthcare 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.

The provider did not always work effectively with people, relatives and healthcare professionals to establish and maintain safe systems of care. Systems for monitoring and responding to people's changing needs were not always robust, and the provider could not demonstrate people's safety was consistently managed through effective monitoring, review and oversight. The absence of consistent monitoring increased the risk that deteriorating health concerns, changes in nutritional wellbeing, or patterns in seizure activity may not be identified promptly, potentially placing people at risk of avoidable harm.

Partnership working with healthcare professionals was not always effective. We found examples where advice and recommendations from external professionals had not been consistently followed by staff. In addition, there was limited evidence people and those important to them had been actively involved in decisions about how changes in their needs should be managed. This meant opportunities to develop coordinated and proactive approaches to care were sometimes missed.

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.

Safeguarding concerns had not been managed promptly or effectively, resulting in delays in identifying risks, implementing protective measures, and ensuring appropriate outcomes for people using the service. We found actions had not been completed in a timely manner, and in some cases had not been completed at all. In addition, safeguarding concerns were not consistently reviewed, processed, investigated, or escalated by the management team responsible for overseeing incidents.

The provider was therefore unable to demonstrate safeguarding systems were robust, effective, or operating as intended. This meant people remained at risk of avoidable harm, as opportunities to mitigate risk, prevent recurrence, and ensure accountability were missed. The lack of effective management oversight, insufficient scrutiny of safeguarding incidents, and failure to ensure agreed actions were completed undermined the provider’s ability to protect people and foster a strong safeguarding culture. Consequently, leaders could not be assured safeguarding concerns were consistently recognised, investigated, learned from, and responded to in a way which promoted people's safety and wellbeing.

The provider understood its responsibilities under the Deprivation of Liberty Safeguards (DoLS). Where required, applications had been made to the local authority and records showed authorisations were monitored.

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.

People were not consistently protected from the risks associated with their care and support needs because risk assessments and risk management plans were not always up to date, accurate, or reflective of their current needs. We found people who required support with medicines administration, moving and repositioning, and safe eating and drinking did not have appropriate risk management plans in place to guide staff on how to provide safe care. As a result, staff did not always have access to clear and current information to support them in managing known risks effectively.

During the inspection, we observed staff using inappropriate moving and repositioning techniques which increased the risk of injury and avoidable harm to people. We observed unsafe medicines administration practices, including the administration of medicines to a person with identified swallowing risks in a manner which was not consistent with safe practice. The absence of robust risk management arrangements meant people were exposed to preventable harm and received care which was not always safe or person-centred.

Furthermore, management oversight had failed to identify and address these shortfalls, resulting in a continued risk to people's health, safety, and wellbeing

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 were not always supported in environments which were consistently safe and well maintained. During the inspection, we identified several homes to be tired in appearance and in need of decoration and repair. We observed holes in walls, rusty radiators, and broken handrails within people's homes. These issues had the potential to compromise people's safety, comfort, dignity, and overall wellbeing. Managers told us they had identified and escalated these concerns to landlords; however, necessary repairs and improvements had not been completed in a timely manner, resulting in ongoing environmental risks for people using the service and an increased risk for people who required support to manage their tenancies

Systems to monitor the safety and suitability of the environment were also not operating effectively. We found environmental audit checks, which were intended to provide management oversight of key areas such as fire safety and legionella monitoring, had not been completed consistently, with weekly gaps in records. This meant the provider could not be assured environmental risks were being identified, monitored, and addressed promptly. The lack of consistent oversight increased the risk of significant safety concerns being undetected, placing people at potential risk of harm and demonstrating weaknesses in the provider's governance and quality assurance arrangements.

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.

Staff were not always suitably trained, competent, or supported to meet the needs of people. Where people required support with moving and handling and the use of specialist moving equipment, we found significant gaps in staff training. Of the 23 staff members working directly with people who lived at a specific location, only 2 had completed appropriate moving and handling training. The remaining 21 staff members had either not completed the required training or their training had expired. In addition, the provider had not ensured staff competency assessments were completed to confirm staff had the necessary skills, knowledge, and confidence to use moving and handling equipment safely and in line with people's assessed needs.

We also found staff supporting people with complex health needs had not received the specialist training or competency assessments required to undertake delegated healthcare tasks safely. For example, staff responsible for administering buccal midazolam, an emergency rescue medicine used to prevent potentially life-threatening prolonged seizures and status epilepticus, had not completed relevant training or had their competency assessed. Furthermore, we identified inconsistencies within a person's epilepsy management records and variation in staff understanding and approach to managing epileptic seizures and administering buccal midazolam. This demonstrated staff did not have a consistent understanding of the protocols required to respond safely and effectively during a medical emergency.

The absence of effective oversight of staff training and competency placed people at increased risk of avoidable harm, unsafe care, inappropriate moving and handling practices, and ineffective responses to significant health emergencies. As a result, the provider could not be assured people were receiving care and support from staff with the skills, knowledge, and competence required to meet their needs safely, consistently, and in accordance with best practice. The widespread training and competency shortfalls represented a significant breach of safe staffing arrangements and exposed people to ongoing and foreseeable risks.

Additionally, the provider had not ensured all staff received a recorded supervision in line with its own policy. This reduced opportunities for managerial oversight, reflective practice, performance monitoring, and the identification of learning and development needs, further limiting the provider's ability to assure itself staff were competent, supported, and delivering safe and effective care.

We found staff had been recruited safely, and appropriate pre-employment checks had been completed, including employment history, proof of identity, and Disclosure and Barring Service (DBS) checks, to help ensure staff were suitable to work with vulnerable people before commencing their roles.

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.

Systems and processes to prevent and control infection required improvement. Standards of cleanliness were not consistently maintained. During the inspection, some people's homes were observed to have insufficient levels of cleanliness, including the presence of strong offensive odours, which had the potential to negatively impact people's wellbeing and increase infection risks. In addition, records demonstrated infection prevention and control audits had not always been completed as required. This limited the provider's ability to effectively monitor environmental cleanliness, identify concerns in a timely manner, and take prompt action to address areas of poor practice.

Staff were observed wearing appropriate personal protective equipment (PPE) when delivering care and support. PPE was used correctly and disposed of appropriately following use, which helped reduce the risk of cross-contamination.

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.

Medicines were stored securely but processes to support their safe use were not always in place.

Although staff were monitoring the temperature of areas used to store medicines, we saw medicines were exposed to higher temperatures. This had not been identified as a concern and meant the quality of the medicine may have been compromised and would therefore, increase the risk of people receiving medicines which aren’t suitable for use.

People had documentation in place to manage their medicines, including risk assessments and updates on their care. However, documentation was often incomplete and not up to date. People who received their medicines covertly (hidden in food and drink) did not always have clear instructions for staff to follow on how to give medicines safely in this way.

Medication administration records (MARs) did not contain clear instructions and relevant safety warnings to support staff with administering people’s medicines safely. Staff reported they had had discussions with the GP and their pharmacy to rectify these issues, but it had been difficult to get these changes made. This meant staff did not have the instructions needed to safely administer medicines to people. We found MARs were not always being used to record the administration of people’s medicines.

Protocols which were used to support staff with administration of ‘when required’ medicines were available, but staff did not always record how effective these medicines had been. One person had a PRN protocol in place for a medicine which was no longer prescribed for them.

Care plans contained some medical information but were not up to date and completed to different standards across the sites we inspected. Some peoples care records did not contain relevant condition-specific information which would support staff to assess the risks involved with people’s medicines and understand how to manage specific emergencies

Medicine audits were not being completed as per the provider’s policy and previous audits had failed to identify issues highlighted on this inspection. This did not provide assurance staff could identify medicine-related safety issues which may arise throughout people’s care.