Lifeways Community Care Ltd (Leicester)

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.

At our last rated inspection we rated this key question Requires improvement. At this inspection the rating has changed to 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 governance.

This service scored 32 (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.

The service lacked a stable and sustainable management structure, and senior leaders had failed to provide effective oversight, direction and support to staff. As a result, staff were often working in isolation and without clear leadership, guidance or challenge. We found staff were making significant decisions about people's care and support which they believed to be in people's best interests; however, these decisions were not always informed by appropriate assessments, professional advice, or a robust understanding of people's needs and legal rights. This placed people at increased risk of harm and the delivery of care was not person-centred or safe.

In some locations, closed cultures had developed whereby staff teams operated with limited scrutiny, accountability or managerial oversight. Practice had become normalised without sufficient review or challenge from leaders, resulting in poor decision-making, inconsistent standards of care and missed opportunities to identify and address concerns. Leaders had failed to create an open, transparent and learning culture where staff felt empowered to escalate concerns and where people's rights, choices and independence were actively promoted and protected. As a result, the provider could not be assured people were consistently receiving safe, high-quality care, and there was an increased risk poor practice could go unrecognised and unchallenged for prolonged periods, exposing people to significant harm and reducing their quality of life.

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.

Despite efforts to recruit service managers into vacant posts, the provider did not have a clearly embedded management structure or sustainable leadership arrangements to ensure effective oversight of people's needs, risks and the quality of care being delivered. The service experienced ongoing staff turnover, particularly with service and area managers.This created instability within the leadership team, hindered the development of consistent management oversight, effective governance and a strong organisational culture.

The widespread and systemic concerns identified during the inspection demonstrated a significant failure of leadership and governance. Leaders had not established a culture which promoted accountability, learning and continuous improvement, resulting in poor practice becoming normalised and going unchallenged. Consequently, the provider could not be assured people were receiving care in line with safe practice, and people remained exposed to ongoing risks had not been effectively identified, managed or mitigated.

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

The provider had systems and policies in place to enable people to provide feedback about their care and support. However, these were not always effective in ensuring the views and experiences of people, relatives and advocates were routinely sought, heard and acted upon. Opportunities for people to share their experiences of the service were limited, and the provider could not demonstrate how they ensured people with communication needs were meaningfully involved in providing feedback about their care.

Relatives told us they were not routinely contacted to share their views about the quality of support their family members received. In addition, people who required staff support to communicate or advocate on their behalf were not always consulted in ways which met their individual communication needs. This increased the risk that concerns, dissatisfaction or opportunities for improvement were not identified or acted upon, resulting in a culture where people's voices were not consistently heard or valued.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff spoke positively about their roles and told us they enjoyed working with the people they supported. Staff said they felt valued by their immediate team leaders and were generally supported within their teams. However, several staff raised concerns staff were not always treated fairly or equitably across the service.

Several staff told us some employees were consistently allocated to support people with more complex needs and those who experienced distress, while other staff were regularly given opportunities to work across different services and settings. One staff member told us, "Some staff are bound to work in locations which are challenging. We are staff of Lifeways and we are supposed to work in all locations. In this location it is very difficult, we are here all the time with no respite." Staff told us they had raised these concerns with management; however, they felt no effective action had been taken to address the imbalance.

This created a risk some staff experienced increased pressure, stress and fatigue, while others had greater access to development opportunities and varied working experiences. Failure to address these concerns could negatively impact staff morale, retention and wellbeing and increase the risk of burnout, which could impact the consistency and quality of care people receive.

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.

Governance and sustainability arrangements were inadequate and failed to provide assurance people consistently received safe, high-quality care. The provider had not established effective systems to assess, monitor and improve the quality and safety of support provided. A High turnover of service and area managers created instability within the leadership structure and significantly weakened management oversight, accountability and the provider's ability to sustain improvements.

We reviewed the provider's auditing system and found significant gaps at each level of assurance. The first level of audits, which support staff were required to complete to enable effective oversight by service managers, were not consistently completed and contained significant omissions. This meant key information was not being effectively escalated or monitored. For example, We found that, although audit checks had identified concerns, action was not always taken in a timely manner to address them. In addition, responsibility for the completion of these actions had not been effectively transferred over when the existing service managers left, resulting in identified risks remaining unaddressed.

Audits which should have been completed at area manager level, had not been completed since the latest area manager left the organisation at the end of June 2026, creating a further gap in management oversight and reducing the provider's ability to identify deteriorating performance or emerging risks. Furthermore, the last audit to be completed at senior management level had not been completed for several months. Whilst the most recent audit completed in April 2026 identified significant concerns and areas requiring improvement, no corresponding actions had been recorded within the provider's governance systems.

These widespread and systemic governance failures demonstrated a lack of effective oversight at all levels of the organisation. The provider was unable to evidence concerns were identified, escalated, acted upon or sustained through effective monitoring processes. Consequently, risks were not consistently recognised or managed, opportunities to improve quality and safety were missed, and the provider could not assure itself, regulators or people using the service that care was being delivered safely, effectively and in accordance with expected standards. This represented a significant failure of governance and leadership and placed people at ongoing risk of harm.

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

The provider had not established or maintained effective partnerships with key stakeholders, healthcare professionals and external agencies to ensure people received coordinated, person-centred care. During the inspection, various stakeholders and health professionals raised concerns with us and with the provider regarding communication, information sharing and the provider's responsiveness to identified issues. Records did not consistently demonstrate timely engagement with relevant professionals, follow-up of recommendations, or effective collaboration to support people's health, wellbeing and longer-term outcomes. This limited assurance people's needs were being managed through a joined-up and proactive approach.

The provider could not demonstrate how partnership working was used to improve people's opportunities, promote inclusion, or support meaningful connections within their local communities. Leaders lacked oversight of concerns raised by stakeholders and partner agencies and could not evidence how feedback was used to drive improvement. This was not consistent with the principles of Right Support, Right Care, Right Culture, as people were not always enabled to access opportunities which promoted independence, choice, inclusion and positive outcomes. As a result, there was a risk people experienced fragmented support and reduced opportunities to live fulfilling lives as active members of their communities.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had failed to demonstrate an effective culture of learning, improvement and innovation. Despite identifying significant concerns through its own quality assurance systems, which had assessed the service as high risk, insufficient action had been taken to drive and sustain improvement. In addition, the local authority had implemented an ongoing action plan and provided continued support and oversight to support service improvement; however, many of the concerns identified remained unresolved at the time of inspection. The provider was unable to demonstrate lessons had been effectively learned, embedded into practice, or translated into improved outcomes for people.

Leaders had not acted with sufficient pace or urgency to address known risks and repeated shortfalls. Governance and improvement processes were ineffective in securing lasting change, and there was limited evidence feedback, audits, incidents, stakeholder concerns, or external scrutiny had been used to drive meaningful service development. As a result, concerns persisted over an extended period, placing people at risk of receiving inconsistent and poor-quality care. This demonstrated a failure to learn from identified issues and implement effective improvements, resulting in a service where known risks and shortcomings continued to impact people's safety, wellbeing and quality of life.