Silverjen Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, staffing (including training and supervision) and safeguarding people from abuse.

This service scored 28 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Where incidents were recorded in care notes there was not always sufficient detail. Often staff were recording the incident in brief and recording that they contacted the office. However, there were no actual incident forms completed. For example, we saw in 1 person’s care notes that they had been taken to hospital. The incident tracker stated the person was taken to hospital for urgent medical treatment however there was no further detail recorded in care notes or on the incident tracker around what led to this or the outcome.

The provider kept a spreadsheet of concerns and incidents raised. We were made aware of 2 incidents that occurred on the first day of our visit on 5 August 2026 including the dressing on 1 person’s wound coming off and a member of staff raising concerns about the behaviour of a person. Neither incident had been added to the spreadsheet or the people’s care notes when we were sent the data on the 10 August 2026. Not having all the information on the spreadsheet meant they could not be assured they were analysing all the incidents that had occurred.

Where people have been prescribed ‘as and when’ sedatives and staff had administered this, there was no analysis in place to review the incidents of distress relating to determine whether staff acted appropriately when administering this. Incidents of distress were not recorded in any detail in order for the provider to establish any themes or trends to reduce the risk of further incidents.
 

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

One relative told us, “The hospital fast tracked the care for [person]. I have not seen the manager. I have not seen a care plan so I don’t know what is supposed to happen or how long the calls should be.”

The provider told us they accepted new packages of care when people were being discharged from hospital. However, they said they had not spoken to the person or their representative to fully understand the person’s needs and preferences around the care they required. This meant the provider could not be assured they could fully meet the needs of the person before care was delivered.

Comments from people about their consistency of care staff included, “I have lots of different carers which bothers me. Some are better trained than others”, “I have several different carers, too many different ones and never know who is going to call” and “Years ago, new carers used to shadow experienced carers, but not anymore they just turn up and are never introduced beforehand.”

The provider failed to ensure there was consistency of care. The rotas showed that for 15 people they had 20 or more different care workers attend to their care calls in July 2026.We also saw from care notes for 1 person that when a member of staff arrived at a care call to cover another member of staff’s break for 2 hours, the staff member covering the break had recorded a concern that did not know the person’s needs. This placed people at risk of not receiving consistent care from staff that knew and understood people’s care needs.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People fed back that they did not always feel safe with staff. One told us, “Some carers are not very gentle, they need to be gentler. They can yank my arm and shoulder sometime which is painful.” We also saw from the service incident reports that other people had raised similar issues about staff being rough with them.

In January 2026, we noted that a safeguarding concern was raised by a family member. This related to a member of staff being observed on CCTV, late at night, entering a person’s home outside of a care call and leaving by the back door. We saw that the provider had undertaken an investigation however, this did not include all the relevant information about the allegation and the recording of the interview with the member of staff was poor. The provider permitted the member of staff to carry with care calls after they concluded their investigation which was not robust. Where other safeguarding concerns have been raised in relation to staff including allegations of physical and financial abuse, on review of the investigations into these, they lacked detail around the investigations. All had concluded with minimal action taken by the provider and the staff were permitted to carry on with their care duties.

The local authority safeguarding team fed back that they also had concerns about the frequency of safeguarding allegations being made including care calls not being delivered as per the agreed time (either too late or too early), medicines not administered appropriately and instances of alleged physical abuse.

There were people that told us they felt happy and safe with care staff. Their comments included, “They are friendly enough and I have got to know them. I feel safe with them”, “They are kind enough and friendly” and “They are very nice people that visit [family member] and they are kind and respectful.” While some relatives reported feeling reassured about safety, this did not mitigate the significant risks identified or the lack of effective systems to prevent abuse and protect all people from harm.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.

We found leaders did not always ensure the legislation was complied with as some people were subjected to restrictions without the appropriate legal authority. For example, we saw from 1 person’s care plan they would often try and leave their home. The care plan stated a low bed, floor alarm and door alarm had been put in place to alert the member of live in staff. However, no capacity assessment had been completed and there was no evidence of a best interests meeting to determine whether any other least restrictive options had been considered.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives fed back that staff were not always safely managing risks associated with their care. Comments included, “Only some of the carers will get me a drink and something to eat but they are always in a rush” and “I feel really rushed in the shower. They hand me a towel, and it is difficult to dry myself due to my disabilities. I will say to the carers I don’t feel dry …but it is ignored.”

There were care plans that contained some risk mitigation guidance for a range of identified health needs. However, we identified examples where formal risk assessments were absent, lacked sufficient detail or did not clearly explain how the level of risk had been determined. Areas affected included, but were not limited to, falls, diabetes, choking, moving and handling, constipation, malnutrition and dehydration. In addition, staff were not consistently recording important information in care records relating to catheter output, fluid intake and bowel movements. This meant the provider could not always demonstrate that risks had always been comprehensively assessed, effectively monitored and safely managed.

However, we heard examples of staff supporting people with their mobility in a safe way. One person told us, “The carers have in the past contacted my doctor when I was unwell. They chased up my new bed and the district nurse when I needed her.”

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

One person told us, “I am not aware that [any senior leaders] had ever completed risk assessments of my home.” The risk assessments relating to the people’s home environments were generic and lacked guidance for staff. Some of these assessments had also taken place without leaders actually visiting the person’s home. This meant that when staff arrived at a call, they did not have specific information about any potential risks.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People fed back staff were frequently not staying for the full length of the call and were often late which they told us impacted them as staff were rushing their care. Comments included, “I get panicky when they don’t arrive on time and I am sitting waiting for them”, “The carers stand around and do very little and always go early”, “They stay for about 15 minutes which isn’t very long”, “Times can vary greatly as to when the carer arrives, we have no firm time. This can really frustrate my [family member] as she has to sit and wait for them” and “If they haven’t done everything they should as they are leaving, I will say ‘you still need to do such and such’.”

There was a lack of organisation by the provider to ensure staff stayed for the full length of time at calls. Although the provider told us, and we saw from rotas, staff were given travel time in between calls, this was not always sufficient, and we saw staff were not always staying for the full length of the call. We also saw that at times staff were arriving late to calls. One person’s care plan stated, ‘Client’s timings are very sensitive and must not be changed without informing the office’. However, according to the rotas for July 2026, there were 16 occasions where staff were arriving more than 30 minutes late. This placed the person at further risk of harm as they were fully dependent on staff for all their care.

We saw from rotas staff were at times working long hours on consecutive awake nights. For example, 1 member of staff worked 24 waking nights 13 of these being consecutive in July 2026. Another member of staff worked 20 waking nights and worked day shits in between with only 4 days off over the entire month. The provider worked 15 awake nights in July 2026 and told us after each shift ended; they would then go to the office and work a full day. Staff working long hours, particularly at night, can lead to physical and mental exhaustion, which can impact staff's ability to perform their job effectively. This placed people at increased risk of harm.

One person told us, “The overnight carers are not as well trained and need guidance on what they are supposed to do.” A relative fed back that they had previous concerns about 1 member of staff not using moving and handling equipment in a safe way. Although the provider removed this member of staff to support other people instead, according to the training matrix the member of staff had not been provided refresher moving and handling training.

The training that staff undertook was not effective in ensuring the safe delivery of care. For example, we saw from the training matrix that 20 staff completed 16-18 e-learning courses on the same day. There was a risk that knowledge retention may be reduced when large volumes are completed together and there was limited opportunity to apply learning between modules. Supervisions were taking place but these were not effective in identifying poor practice based on the concerns we identified with the delivery of care throughout this report. This included safeguarding, medicines and risk management.

However, staff working at the service had evidence of previous employment, their right to work in the UK and their fitness for the role. Each staff member underwent a Disclosure and Barring Service checklist prior to working independently.

The provider did not always assess or manage the risk of infection.

People told us staff did not always wear appropriate uniforms or personal protective equipment [PPE]. Comments included, “They wear their gloves when they help me shower, they don’t wear aprons” and “Some carers arrive wearing flip flops which is so unprofessional, even if it has been very hot.” The local authority fed back that on a recent visit to a person’s home they observed the member of staff was not wearing an appropriate uniform. There was a risk that staff not wearing appropriate PPE would spread harmful germs to other people when going on to other care calls.

However, from the visits we undertook for people, we noted that people’s homes were kept clean and tidy. We also noted that staff had access to sufficient PPE.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Whilst there were some people who received their medicine as prescribed, there were elements of the management of medicines that were unsafe. For example, awritten ‘as and when’ protocol was in place for a person. However, the protocol did not contain sufficient person-centred detail to guide staff on the specific circumstances in which the medicine should be administered, the desired outcomes, or alternative measures that should be considered before administration. We also identified concerns regarding the recording of ‘as and when’ medicine administration and whether records consistently demonstrated the rationale for administration and outcomes achieved.

A member of staff told us 1 person’s medicine was placed in an electronic dispenser [arranged by the family] which gave an alert when the medicine was ready to be taken. The member of staff told us they would hand the medicine to the person [who had a cognitive impairment] to take. However, they said they did not know what the medicines were or what they were for and there was no medicine administration record [MAR] in place. The lack of a MAR meant there was no formal proof that medication was taken, monitored, or managed safely. This left the person at risk of not receiving their correct prescribed medicines and at significant risk of harm to their health.

Medicine competency assessments were not always effective or accurate. We saw assessments were at times undertaken when a carer was not logged into the call suggesting it could not have taken place. Two assessments stated the member of staff passed the observed assessment, yet it was recorded that the person was not administered medicines by staff but by their families. This meant the provider could not be assured that staff were competent in medicines administration.