Updated 30 January 2025
Sister Winifred Laver Promoting Independence Centre provides accommodation with personal care for up to 60 people. 52 people were using the service when we visited, some people were living with dementia. This unannounced assessment was due to whistle blowing concerns about poor medicines management and poor care at the service. We visited the service on 5 and 10 February 2025 and found breaches of the regulations relating to safe care and treatment, person-centred care, consent to care, good governance and staffing. Ineffective leadership and a lack of oversight had led to significant shortfalls, placing people at risk of harm, including poor record keeping, ineffective risk management and not reporting serious incidents. Management had not learnt from previous experiences and taken robust action to address known issues. Risks associated with people’s individual circumstances had not been managed appropriately. Medicines were not managed safely. Staff did not feel valued or supported and told us management did not listen to their concerns. The provider had not sought appropriate consent for restrictions on people lacking capacity, such as for bed and chair sensors. Care plans were not person-centred, accurate or up to date. Falls, incidents, accidents and allegations of abuse were not effectively analysed to learn lessons. The service has been placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.