Lifeways Paragon Limited (North West)

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Medicines were not being managed and stored safely and risks to people had not always been taken into consideration. Infection prevention and control practices were not always robust and we found concerns with the environment people lived in; however, some of these concerns were outside of the provider’s control. Lessons were not consistently being learnt and we found gaps in staff training.

Staff recruitment processes were overall robust and accidents and incidents appeared to be managed well. People were protected from the risk of abuse.

The service was in breach of legal regulation in relation to safe care and treatment.

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Consent forms were not always signed, and restrictive practices were not always carried out lawfully and safely. Support plans were not always up to date and people’s goals and ambitions for the future were not always documented. Oral care plans were not always in place and we found staff training to be lacking in this area.

Some relatives told us they were involved in the support planning process and they felt people were encouraged to live an active, healthy lifestyle where people’s independence was encouraged.

The service was in breach of legal regulation in relation to consent.

Caring – this means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were supported and treated with dignity and respect; and involved as partners in their care.

People were treated with dignity and respect and people appeared comfortable around the staff team. People chose how they spend their time and meaningful activity was provided. Staff responded well to people’s needs and staff felt managers listened to concerns.

Not everyone’s support plan included goals and ambitions for the future and people’s individual needs had not always been documented.

Responsive – this means we looked for evidence that the service met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people’s needs were met through good organisation and delivery.

Staff provided person-centred care and offered people a choice. A complaints procedure was in place and feedback was sought from people and their relatives. The services had been made accessible to suit people’s individual needs and people were actively encouraged to go out into the community.

Not everyone was aware of relative meetings and people’s communication needs had not always been taken into consideration.

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Governance processes needed strengthening to ensure concerns were identified and lessons were learnt. Audits did not always pick up on concerns found during the assessment process and not all staff knew how to access the service’s policies and procedures.

Staff spoke highly of the registered manager and felt supported by the management team. People were actively encouraged to attend community groups to enhance their wellbeing.

The service was in breach of legal regulation in relation to the governance of the service.