Silver Howe

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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Systems were not used effectively to identify concerns about safety. The registered manager did not always investigate and report safety events. Lessons were not being learnt to continually identify and embed good practice.

There was an electronic accident incident recording system in place since December 2025. However, accidents that were recorded any actions taken were not always being identified. There was no evidence of these reports being regularly reviewed by the registered manager. The recording systems were not being used effectively meant opportunities for reviewing actions taken, identifying preventative measures and learning lessons were being missed. Previous paper records for accidents and incidents for 2025 were made available however, nor did these capture actions taken, preventative measures or lessons learned.

Some statutory notifications required to be sent to us after accidents and incidents had not always been made for example where referrals were made to the local authority safeguarding team or for some serious injuries that had occurred. We saw family’s and relevant other were usually informed of accidents however the recording of the duty of candour did not show this was always being recognised and considered.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager completed preadmission assessments to identify if people’s needs could be safely met by the service. Some people and their relatives told us they had been involved in developing care plans on admission. Processes were in place to help ease transition to other services if needed such as emergency hospital admission information.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider did not always share concerns quickly and appropriately with us. Where procedures and practises were in place to deprive people’s liberty this was not always recorded in line with requirements of the Mental Capacity Act 2005 (MCA). Staff supported improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Where people lacked capacity and had their liberty restricted there was no evidence of how that had been considered by the provider under the MCA. There were no electronic records completed for consents or how it had been obtained. DoLS were applied for however historical applications had not been reviewed regularly to ensure any changes in people’s needs had been captured.

People and their relatives told us they felt the service was safe. One relative told us, “[Relative] is safe and well cared for.” Incidents of safeguarding had been identified and shared with the local authority. Staff had completed training in safeguarding awareness, MCA and DoLS.

The provider did not work well with people to understand and manage risks. Risks related to peoples’ care and treatment had not always been recognised or documented accurately.

We found some records for managing identified risks were not in place or were not always accurate and current. The risk assessments we noted as being required or amending were completed by the registered manager during the inspection. People’s needs and associated risks were regularly being reviewed however, some records were not always reflective of peoples’ changing needs or current needs.

We could not be fully assured that people were not at risk of dehydration or at risk of pressure ulcers developing because records for their fluid intake and repositioning were not accurately recorded. However, we did observe throughout the inspection that staff regularly gave and encouraged people to drink fluids. We observed positive interactions by staff with people who could not easily express their needs or became distressed.

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

Regular environment, equipment safety checks and regular servicing were in place. On our walkaround we saw some risks in the environment including topical prescribed creams not always being stored safely. The registered manager took immediate action to address this. There was an ongoing programme for repair and refurbishment in the home. Externally there were some uncompleted building works.

Staff were adequately trained in fire and evacuation and the use of equipment. The design and décor of the environment had been considered to meet the needs of those living with dementia.

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

A dependency scoring tool was used to determine the ideal number of staff required however, we were not fully reassured that this had been completed correctly to reflect the level of people’s needs. Gaining entry to the home took a long time and the call bell log also showed this.

Four people we spoke with told us they had to wait for a response to their call bell, with one person saying the response by staff was quicker during the night. One relative felt there should be more staff. Two staff said there could be more staff at certain times. We observed the lunchtime experience on the first day with 5 staff available and it was seen to be very disorganised. There was no leadership or direction for staff resulting in people being repeatedly asked the same question. People in the main dining room were not supported by any staff member, and one person was seen to become agitated and unsettled impacting on other people. The subsequent days we visited there were 6 staff and the lunch time experience was seen to be a more smooth and calmer experience for people. The registered manager told us the increase in staffing was because people’s needs had changed.

We noted training on eLearning some topic areas still need to be completed by some staff including dementia awareness, MCA DoL’s training and not all staff had completed any specialised dementia training. We saw induction checklists had been completed by new employees. Staff told us they felt they had received sufficient training to care for people safely. Most people we spoke with thought staff had been appropriately trained.

Staff told us they felt very supported by the registered manager and told us they received regular supervision. Staff had been recruited safely with appropriate checks of suitability being made prior to their employment.

The provider had not always assessed and managed the risk of infection. The home was working on an infection prevention action plan following a recent audit by the local public health team.

We observed the home was clean and regular checks of the cleanliness and infection prevention were being completed. Some rooms not in occupation needed deep cleaning and or repair. Personal protective equipment (PPE) and hand sanitiser was readily available and seen to be used effectively. People we spoke with were happy with the quality of cleanliness in the home. Food handling and hygiene was done in line with best practice.

The provider did not make sure that medicines and treatments were always managed safely.

Topical medicines were not always stored safely. Protocols in place for administering as required (PRN) medicines were not always accurate and these were amended immediately by the medicines lead. Records to show the reasons why and times administered for PRN medicines was not consistently recorded. Records to ensure the rotation of skin patches were not completed sufficiently to ensure applications had been rotated. Medication administration records (MAR) did not all contain the brought forward balances of stock. Stock checks we completed were not accurate for 2 types of medicines we checked. The audit tool used for random stock checks weekly was not completed correctly. The audits completed by the compliance manager for November and December 2025 evidenced a continuation of the same concerns showing that any actions identified were not being addressed in a timely manner.

Staff had had completed medicines training and had their competency regularly assessed. A weekly ’ward round’ by the GP surgery was done and support was available from their pharmacist.