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

We found the service could not sufficiently demonstrate the safe management of medicines. There was a lack of guidance for the safe administration of medicines and best practice was not always followed. This resulted in a breach of Regulation 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Evidence reviewed showed that the service had infection prevention control (IPC) systems in place to maintain safe environments. People were supported by staff who understood their roles and responsibilities in order to protect people from abuse and the risk of avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt safe in the care of staff from Lifeways Community Care Ltd (Leicester). People's relatives told us they were confident that the service safely cared for their loved ones. However, there were occasions where incidents had been recorded, but no further actions were recorded to demonstrate the mitigation of risk. Therefore, we could not be fully assured that people were always safe.

Staff were aware of their responsibilities to protect people from abuse and avoidable harm. They told us how they would raise concerns both within the service and externally. Staff understood how to ensure people’s rights were fully respected and had received training in safeguarding people from harm and knew how to access the relevant policies and procedures. However, due to inconsistent recording and analysis, we were not fully assured that staff always had the required information and guidance to keep people safe.

Safeguarding concerns were recorded by the service; the records showed all necessary referrals had been made. Internal investigations were completed as and when required, and actions were put in place to reduce future risks. However, the registered manager did not always review and analyse every incident in order to implement actions required to reduce reoccurrence. It was also identified that there were some inconsistencies surrounding the recording of decisions made in people's best interests.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us there were enough staff to meet their needs. However, we received mixed feedback about the skills and competency of staff in meeting people's individual needs. The registered manager addressed these issues during the assessment process.

Staff were positive about the numbers of staff within the service and told us they thought there were enough staff to meet everyone's needs. They confirmed there were always sufficient, skilled and experienced staff available.

Staff were recruited safely. Records were maintained to show checks had been made on employment history, references and the Disclosure and Barring Service (DBS). DBS checks provide information about convictions and cautions held on the Police National Computer. This information helps people make safer recruitment decisions. Staff received opportunities to discuss their work, training and development needs. The provider’s internal review identified some improvements of staff supervisions and appraisals were required. Records confirmed this had been discussed with service managers and team leaders to ensure improvements in this area.

There were infection prevention and control systems in place. Relatives told us staff supported people to maintain a safe and clean environment. However, some concerns were raised about a recent issue within one home. We fed this back to the registered manager for resolution. Relatives confirmed staff wore personal protective equipment such as aprons and gloves. A relative said, “I’ve seen staff wear it (PPE) its’s available, I’d say yes they do.”

Staff confirmed they had completed infection prevention and control training and how they supported people to maintain their tenancy, including support with health and safety checks, cleaning and managing infection outbreaks. A staff member said, “Staff have a supply of PPE and wear when assisting with personal care, administering medicines, serving food and cleaning".

Staff had received training in infection control practices and used personal protective equipment (PPE) effectively and safely. Some concerns were noted regarding the cleanliness of one home and fed back to the registered manager and wider leadership team. The provider evidenced lessons learned following a recent issue within one home and new procedures had been implemented to prevent this from reoccurring.

Feedback from relatives about the safe management and administration of medicines was positive. Relatives were confident medicines were managed and administered safely. A relative said, “Yes, medicines are managed safely and get reviewed.”

Staff told us they had access to medicines training and had their competency assessed. The medicine policy was readily available to staff and they told us how they follow safe practices in line with processes and procedures. However, we could not be assured that medicines were always safely administered as the guidance for staff was not always clearly documented.

People's medicines were not always safely managed. Staff did not always follow best practice guidance and there was a lack of information to allow staff to safely administer medicines. As and when required medicine (PRN) protocols did not always provide sufficient guidance to support staff in administering. For example, care plans referred to a person requiring medicine for 'pain' but limited details were provided on how to identify when a person is in pain. Staff didn't always record a reason for administering a PRN medicine.