Sister Winifred Laver Promoting Independence Centre

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. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Support and therapy staff told us there wasn’t a positive culture within the service. They described how there needed to be better communication between management, that manager’s did not listen to and involve them in decisions, and that they did not feel supported or treated equally. The provider had not been successful in creating a learning culture to ensure people received safe care. The registered manager told us they were committed to improving the service for all.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. It was unclear what systems were in place to demonstrate the registered manager and provider had effective oversight of all aspects of the care being provided. It was also not evident what quality assurance checks the registered manager carried out to monitor people’s safety and wellbeing. Support and therapy staff consistently told us leadership needed to improve to ensure people received a seamless service which promoted good outcomes.

People did not always feel they could speak up and that their voice would be heard. The provider had a whistle blowing policy. However, staff consistently told us management did not listen to their views and did not provide feedback when they raised concerns or made suggestions.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had received negative feedback in their most recent staff survey, where 55% of the staff who had responded stated they did not feel valued. The provider told us they had taken action to improve this. Support staff also told us about additional pressures placed on them, such as rotas and holidays not being agreed in a timely way.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider and registered manager were unable to evidence effective governance and quality and assurance systems were in operation. There was no clear structure about who was responsible for checking the quality of people’s care. This meant there were significant shortfalls identified, which the provider had not been proactive in dealing with. This included lack of robust auditing to ensure care planning was fit for purpose. No improvements had been made from previous inspections from the local authority or surveys and there was a lack of action planning following staff and people’s feedback. The service had a process for weekly medicines audits. These ensured medicines were in stock and available for staff to administer. However, the audit was limited and did not look at all processes of medicines management. This contributed to the lack of medicines management oversight at the home. The quality of people’s care records required significant improvement. The registered manager told us the duty managers completed care plan audits. However, they acknowledged these were not recorded.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Support and therapy staff told us teamwork was challenging, as different groups of staff had their own priorities to focus on. They described a lack of leadership and co-ordination to ensure they worked together effectively.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Weekly medicines audits were not analysed to identify issues and learning. The provider was also not analysing incidents and accidents to identify learning to help keep people safe. The provider and registered manager had failed to take robust action from previous experiences. There were no regular documented audits of care plans and there had been no improvement to the quality of care records despite an internal local authority inspection in October 2024 reporting they were ‘very substandard.’ The provider had also not taken effective action to improve staff members experience of the service. Staff feedback gathered during this assessment was similar to the poor feedback the provider had been made aware of in the last staff survey.