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. At our last assessment we rated this key question inadequate.

At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service continued to be in breach of legal regulation in relation to governance at the service.

This service scored 46 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Improvements had been made and there was a more positive culture within the service. Some staff continued to give mixed feedback about communication, teamwork and support. There was also mixed feedback about staff morale. A staff member commented, “Morale is up and down at the minute.” The provider had plans to improve this further.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The manager had changed since our last inspection and was in the process of registering with the CQC. We received positive feedback about the manager. A staff member said, “I find [manager] approachable. I feel that if I had an issue I would be listened to.” Systems had improved to ensure management, and the provider, had greater oversight of the service. However, these needed more time to be fully embedded.

People did not always feel they could speak up and that their voice would be heard. We continued to receive mixed feedback about staff feeling confident to speak up and voice their concerns. A staff member commented, “Management don’t keep you in the loop with everything we need to know.”

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.

Although staff feedback had improved since the last inspection, some staff still had concerns about aspects of the service including communication, support and teamwork.

The provider did not have clear responsibilities, roles, systems of accountability or 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 had introduced a more structured system of quality assurance. Audits were being completed more consistently than at the previous inspection and were identifying some issues. Although the systems had improved, more time was needed to embed processes and to ensure they were effective in driving through sustained improvement. For example, there were still shortfalls in effective care planning which the provider had identified but not yet addressed fully.

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.

The provider was working with a range of external partners to improve and develop the service. They had made progress with their action plan following the last inspection. However, further time was needed to embed new procedures to ensure they could deliver sustained improvement. A staff member commented, “Everything is starting to come together now.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had improved the systems to monitor the service and to learn lessons. Falls, incidents and accidents were now being analysed regularly. However, the analysis lacked detailed and required further time to be fully effective.