Lionheart Domiciliary Care Services Limited - Deptford

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

Well-led – 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 assessment, we rated this key question requires improvement. At this assessment, the rating has remained requires improvement.

This meant management and leadership was inconsistent. Leaders did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance, which was related to record keeping and quality assurance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a statement of purpose, a set of values and expectations and a code of conduct in place and these were given to and discussed with staff.

The registered manager said, “Staff are given a handbook, it includes the values, code of conduct, expectations and important contacts details” and “Managers and staff do EDHR training.” EDHR stands for Equality, Diversity and Human Rights.

A member of staff told us, “I was given a staff handbook. It has the values, the company's code of conduct and its policies and procedures.”

Another staff member said, “I have a staff handbook, it was sent to my email. It includes company values and staff conduct.”

Not all leaders always had sufficient knowledge and skills to lead effectively.

The registered manager needed to improve their knowledge, understanding and implementation of medicines management, and improve the effectiveness of the service’s quality assurance systems and processes.

However, leaders were inclusive and embodied the culture and values of their workforce and organisation and managed the service with integrity, openness and honesty.

A person’s relative told us, “Anything that is wrong they [the provider] will always let me know.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider carried out staff feedback surveys and analysed the information to improve the service.

Office staff had a meeting every week to discuss the service and any issues. There was a full staff meeting each month where care staff could discuss issues. The provider had an ‘open-door’ policy, which meant any staff could discuss anything with the managers at any time.

Staff were provided with the whistleblowing policy and procedures and knew how to raise concerns outside of the service.

Staff told us they felt comfortable to raise concerns and give feedback.

A member of staff said, “They [managers] do a staff survey. I feel comfortable to give feedback and raise concerns.” Another staff member told us, “If I have an issue, I usually call my care co-ordinator, and they usually help me out.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Managers and staff received EDHR training and were aware of the 9 protected characteristics under the Equality Act 2010.

A member of staff told us, “They [the provider] work flexibly with the rota, I had to take my [son/daughter] to the hospital and they rearranged my shifts. I am happy, they [the provider] treat me well, so I don't have any problems.”

Another staff member said, “They [the provider] are flexible with the rota. I like working here, I am happy, I have had no negative experiences.”

The provider did not always keep contemporaneous records of people’s care and support, and their quality assurance systems and processes were not always effective.

The provider’s reviews and audits had notidentifiedthe issues we foundduring our inspection. This meant some of the provider’s audits had not always given a true picture of the situation, and therefore, the provider had not always been able to identify learning to improve the service. This had led to the issues we identified regarding the moving and handling of people, medicines management, record keeping and people’s needs and risk assessments and care plans not always being up to date.

The provider had not kept written records of when people’s medicines had been started and stopped and had not always kept contemporaneous records of a person’s food and fluid and repositioning charts. These charts were in place, and during our inspection we looked at the charts for March 2026. However, the provider had not always retained contemporaneous records of previously completed charts. This meant we could not always be assured people had always received their care and support in line with their needs and in a safe way.

People’s needs and risk assessments and care plans were not always up to date. This meant staff may not have always had the best information to support people and keep them safe, which could put people a risk of potential harm.

These issues were a breach of Regulation 17: Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found no evidence anyone had been harmed.

The provider had clear responsibilities, roles and systems of accountability in place. Staff had contracts of employment that set out their roles, responsibilities and duties.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners.

The provider worked in partnership with GPs, local authorities, social workers,occupational therapists, district nurses and speech and language teams, for example, to ensure people received the right care and support in a timely manner.

The provider had not always focused on continuous learning, innovation and improvement across the organisation.

The issues we found regarding the provider’s reviews and audits meant the provider’s quality assurance systems and processes were not always effective. This meant the provider had not always identified learning to improve the service. The way the provider operated their audits required improvement to make them effective.

The provider did contribute to safe and effective practice across local systems.

The service was linked in with Skills for Care and used its Care Certificate to guide and train staff. Skills for Careis the workforce development and planning body for adult social care in England. It provides a range of resources and support to help employers and workers develop their skills and improve their services. Its Care Certificate is an agreed set of 15 standards that define the knowledge, skills, and behaviours expected of health and social care workers.

The registered manager was a member of a support network for registered managers and regularly met with the group to discuss issues and share learning.

The provider received updates about legislation and practice from local authorities and CQC and used them to improve the service.