Lifeways Community Care (South London) was rated Good overall at its first inspection of the newly registered service in January 2023, with people feeling safe and well cared for by kind, knowledgeable staff. Well-led was rated Requires Improvement due to record-keeping failures, unreported notifiable incidents, insufficient staff deployment to meet funded hours, and people not consistently being engaged in feedback or tenants meetings.
Concerns (7)
critical
Governance
: “We reviewed the accident and incident records...and found some notifiable incidents had not been reported to CQC.”
moderateRecord keeping: “One person had moved to a downstairs flat due to their mobility deteriorating, however their support plan did not reflect this as it still recorded they were on the second floor.”
moderateRecord keeping: “A second person would become distressed if staff mentioned their mother and yet this was not in their support plan.”
moderatePerson-centred care: “People were not always encouraged to give their views or to be involved in the day to day running of their home.”
moderateStaffing levels: “Another person used to go out with 2 staff on a daily basis, but this was no longer the case...limited to going out only twice a week as there was insufficient staff.”
moderateMedication management: “Some people's allergy section on their medicine administration record (MAR) was blank...also a lack of information on how people liked to take their medicines.”
minorSupervision / appraisal: “Some staff did not always feel supported by their manager or senior management and they felt isolated in their roles.”
Strengths
· People felt safe and expressed positive views about staff kindness and care.
· Robust staff recruitment process including DBS checks and right-to-work verification.
· Staff received required training including infection control, epilepsy, and manual handling.
· Staff worked effectively with external agencies and healthcare professionals.
· Support plans contained person-specific information including health, mobility, and communication needs.
Quality-Statement breakdown (22)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Working in partnership with others; Continuous learning and improving careRequires improvement