Silverjen Limited

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 requires improvement. At this assessment the rating has changed to 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 29 (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.

People and relatives raised concerns about the running and culture of the service. Comments included, “My family are also concerned that they have no access to notes that are being recorded as to the activities the carer has undertaken during my calls”, “If they are going to be late, they don’t contact me so that is frustrating” and “They [staff] are on their phones quite a bit talking in their own language to someone”.

We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights to be free from abuse and neglect. There was a closed culture where staff did not always feel they could raise concerns.

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.

People and relatives told us there was poor communication from the office. Comments included, “There is no communication from the company. I ring and try to get a hold of someone in the office and there is never any reply”, “There no longer seems to be any transparency about the company’s policies and procedures” and “There needs to be more proactive management and the rotas need to improve.”

We found the leadership team was not always open and transparent with CQC. Throughout the assessment we were not always given accurate information from the provider and senior staff. For example, the provider told us that all office staff [including themselves] only covered the occasional care call when there was staff absence. However, we saw from rotas in May and July 2026 that the provider and the office staff were routinely rostered to provide multiple care calls. In addition, the provider told us they had not taken on any new staff since the last assessment in December 2025.However, we saw from the training matrix, that staff there were staff that had started working at the service from February 2026 to date.

The leaders of Silverjen did not have the skills or knowledge to lead effectively. They had not recognised the closed culture at the service, or the detrimental impact this had on people being supported. They lacked knowledge about the issues and challenges at the service and did not appropriately challenge poor or inappropriate practice. Although staff told us leaders were supportive, we found they had failed to ensure staff were working with a care rota that was manageable.

However, there were comments from staff stating they felt supported. These included, “I am happy at Silverjen. They look after me. If there is any challenge or if I’m not well, they will allow me to go” and “I feel supported, if I need a break, I have my leave days. I have never had any challenges.”

People did not feel they could speak up and that their voice would be heard.

People and relatives in the main, told us when they raised concerns, no action would be taken. One person told us, “One morning, a carer was shouting at me and I was crying, my [family member] heard all this and rang the manager. I don’t know what the manager has done about this incident after my [relative] had called.” A relative told us, “Even although we have raised complaints with the office about some of the carer’s attitudes, timings and length of calls they still keep sending the same carers who I don’t really know. Some people and relatives told us that because of this lack of action, they had stopped contacted the office.

Although the majority of staff told us they were able to speak up, there was no evidence of any discussions by staff with the leaders to discuss their concerns around the lack of travel time and that they were unable to spend the entire planned care call with people.
 

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.

There were staff who felt the leadership team were inclusive and valued diversity. However, we found there was a lack of equality in how all staff were treated. For example, the majority of the ‘live in’ staff were only able to travel using public transport. However, they were required to travel on their breaks, by public transport, to the office to pick up essential PPE. Staff also raised this concern with 1 telling us, “I would prefer if the PPE was dropped here.” In addition, the provider failed to ensure that ‘live in’ staff were always provided with their 2-hour break.

In addition, staff that were required to work in the office to manage the oversight of care calls, oversight of care and staffing, were not given sufficient time to do this due to having complete care calls in addition to these duties.
 

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.

People and relatives fed back that there was a lack of governance in place. Comments included, “I have spoken to [office manager] on the phone but [office manager] hasn’t visited”, “There have been no management spot checks to see if the care is being provided well”, “The managers never come out to see me now for a review and discuss our issues” and “There are so many things that need to be improved.”

Systems in place to monitor the delivery of care were not robust and this impacted on the care that people received. The provider told us staff used an electronic portal to sign in to calls when they arrived and when they left the person's home. The provider told us they used this system to ensure staff turned up for calls and they stayed for the duration of the call. However, there was no robust oversight of this. We identified from records staff were regularly not staying for the full length of the call. The provider told us if staff were running late or had missed a call they would be alerted by the online system. However, given the office staff and the provider were frequently undertaking calls, this was not effective as the office staff would have been busy providing care.

There were insufficient systems in place to robustly audit the care and make improvements where concerns had been identified. Governance records relied on people's initials as the sole identifier and did not contain additional unique identifiers. Given the size of the service and the presence of people with the same initials, this created a potential risk of ambiguity when records were reviewed. Whilst we did not identify evidence that records had been attributed to the wrong person, the provider could not demonstrate that governance processes consistently minimised the risk of confusion and ensured records were clear and unambiguous for all staff reviewing them.

We asked to see audits of the quality of care being provided and these lacked detail on areas for improvement, and where they did, they had not recorded when action had been taken. The audits they did not identify all the concerns we found.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Whilst the leader shared some health concerns with professionals about people’s needs, the provider had not taken steps to share their concerns around the level of packages of care that were not being managed well or safely. They continued to accept packages of care without considering the impact of this. The provider also failed to respond to all requests for information from the local authority safeguarding team in a timely way.

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.

Although we could see there were reviews undertaken for incidents that occurred, there was no update on the analysis record of what actions had been followed up or completed. For example, in June 2026 it stated that the priorities for July 2026 were to plan for delayed ambulance response to ensure a member of staff could stay with the person whilst another member of staff was deployed to complete their next care call. Another action was to ‘investigate the high severity fall’ for a person. The audit had not been updated to state that these actions had taken place.

We noted from the concerns and incident data provided by the service, people and their representatives were feeding back that care calls were often late. Despite this, there was a lack of action taken to address this and make the necessary improvements. We saw from the July 2026 rotas there remained multiple incidents of staff arriving late for care calls.

The provider told us that in January 2026, the local authority had raised the concerns about the multiple training modules being completed by staff in a short space of time. However, the provider had not any action to address this to make improvements when new staff started.