Silverways Nursing Home

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 safe care and treatment.

This service scored 56 (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. They did not always listen to concerns about safety and did not always investigate and report safety events.

The service shared some information. However, we found the systems and processes in place for recording accidents and incidents were not effective. This meant not all incidents were appropriately investigated and care plans and risk assessments amended as a result. For example, following a choking accident the person’s care plan was not updated to ensure staff knew how to best support them. The registered manager ensured the relevant documentation was updated following our feedback.

Lessons were not always learned. For example, ensuring mattress pump settings were set in accordance with people’s weight were discussed at the team meeting in February 2026. However, during the inspection we found mattress settings were not always set correctly. This placed people at risk of developing pressure sores.

People and their relatives told us they knew how to raise concerns with the management of the service. A relative said, “If I had an issue, I would firstly approach the care home manager before escalating it.”

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.

Relatives told us they felt the service communicated with health and social care professionals when required. A health and social care professional told us, “All of the families and the residents have been extremely happy with the care provided to them by Silverways and have praised the care home.”

Records showed the service consulted with external health and social care professionals when required and had an established process in place to ensure people’s information was available if the person was admitted to hospital.

The provider did not always share concerns quickly and appropriately.

Most people and relatives felt the service was safe. One person said, “I feel safe here, there is always someone around.” However, another person said they did not feel safe as the service was accepting more people with complex needs and the service was not an appropriate place for them.

Staff told us they felt people living at the service were safe and they knew how to raise safety concerns within the service. Staff were aware they could report their concerns externally to the local authority or CQC. One staff member said, “I believe our clients are safe, we tried our best to keep the residents safe. We used the alarm mat or seat mat to prevent falls, we inform the nurses promptly if we notice changes in behaviour or mobility. If changes in skin integrity we update the care plans.” Another staff member told us, “I can report it to directly to our registered manager or [if] there’s a need to report it outside of the home, I can report it to CQC.”

We found most concerns were reported to the local authority without delay. However, some incidents and accidents had not been raised as safeguarding concerns when required. In response to our feedback the provider developed a plan to improve the systems and processes in place, to ensure the necessary safeguarding referrals are made. As a result of our inspection, some concerns were reported to the local authority retrospectively.

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). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). 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. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected. The registered manager had oversight of DoLS applications.

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

The service assessed risks to people’s wellbeing. However, we found some risk assessments contained contradictory information and were not always reflective of the support people required. For example, a person who was at risk of being underweight and overweight at the same time or another person who was nursed in bed and had a falls risk assessment. This meant people were put at risk of avoidable harm. The registered manager responded to our feedback and started the process of reviewing people’s information.

The registered manager told us the service assessed people’s needs before admitting them to the service to ensure they could safely support them.

The service offered relevant training and had an up-to-date positive support policy.However, some staff told us this was not always sufficient to safely support people with known risks. We received mixed feedback on how much time and training staff felt they had to support people with complex needs. Some staff told us they did not always know how to support people who displayed distress or anxiety due to their medical conditions. Comments included, “I have regular supervision and team meetings where we have opportunities to discuss people’s complex needs. We also have face to face training and online training to enable staff to support these types of residents”, and “We put some of the issues in ABC chart, but they are not being addressed, and we get to see all the issues occurring again.”

An ABC [Antecedent (trigger), Behaviour (action), and Consequence (result)] chart is an observational tool used to identify the causes, triggers, and patterns of distressed behaviour in people.

The provider did not always detect and control potential risks in the care environment. For example, scissors were accessible to people in communal areas. Following our feedback, the provider removed all items, therefore removing the immediate risk to people’s health and safety.

Some fire doors were incorrectly labelled, and some were not locked. The provider purchased locks and started to fit them on the relevant doors. Action was taken to review fire door labelling to ensure compliance.

We observed air flow mattresses were checked daily. However, the system in place was not effective and staff were checking the settings against incorrect information. This meant when people put on or lost weight, their mattress settings were not adjusted. This put people at risk of avoidable harm of developing pressure sores. In response to our feedback the provider implemented a new system to ensure compliance and checked all mattress settings against people’s current weight.

People had Personal Emergency Evacuation Plans (PEEPs) in place to provide information on how people would need to be supported in the event of an emergency at the service.

The service used external contractors to undertake some of the environmental checks such as gas, electrical and water hygiene, which were all in place.The provider implemented some safety measures, such as covers on the radiators and window restrictors.

Staff told us they knew how to report concerns relating to the environment. One staff member said, “I report issues to the nurse on duty, who then passes them on to maintenance. Most issues are addressed promptly. For example, faulty equipment or hazards are reported in the maintenance book and resolved as soon as possible.” Another staff member told us, “If we have some issues about the maintenance or environment, we reported that in the maintenance book.”

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

People and relatives told us they were happy with the staff who worked at the service. A relative said, “There are always staff nearby, staff frequently put their head round the door to offer drinks, activities etc. [Person’s] call bell is always within reach, because they are at risk of falling and are often confused. [The service] have fitted devices to alarm when [person] gets out of the bed or chair and are there within seconds when the alarm triggers.” A person said, “Staff are wonderful, very caring and friendly. They have all become my friends.”

We observed people had access to their call bells and staff responded to people’s needs promptly. However, some people felt there was not always enough staff on duty to support them. One person said, “Sometimes they are short of staff, and I have to wait to be taken to the toilet.” Another person told us, “Sometimes it is over 10 minutes, because they are attending to a dementia patient, this is a nursing home. Like yesterday I used the bell, it took over 10 minutes for them to come. But all of the senior staff are genius and good.”

Staff confirmed they had regular supervisions and team meetings.

Recruitment procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The service assessed and managed the risk of infection.

Relatives were complimentary about the cleanliness of the service. A relative told us, “The home is very clean, and we have spoken to cleaning staff and praised them for it.”

Staff confirmed they had access to personal protective equipment (PPE) to use when needed. One staff member said, “I have completed infection prevention and control training and follow guidelines such as hand hygiene, use of PPE, and cleaning procedures.” Another staff member told us, “I have all the PPE (gloves, cover shoes, apron, facial mask). We have the cupboard [with] the supply, if some of the stuff is missing, we inform the line manager or the team leader and they will provide to supply them.”

We observed the service to be clean and free of clutter.

The provider had an infection control policy in place and staff had access to the relevant training.

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

Medicines were not always kept safely. Some people did not receive their medicines as prescribed. The provider did not always have safe systems in place to manage medicines in a way that met people’s individual needs and preferences.

We found that one of the medicines fridges had been operating below the minimum safe temperature of 2°C for at least three months. This had not been escalated to the manager as set out in the provider's policies. As a result, medicines requiring refrigeration were not stored in line with manufacturers guidance and therefore may not be safe for administration, placing people at risk of harm.

Some people were prescribed time critical medicines for Parkinson’s disease. However, we found that these medicines were not always administered in line with prescribed times. National guidance and the provider's medicines policy states that these medicines should be administered within 30 minutes of prescribed administration time. We reviewed the records of 2 people that were prescribed these medicines and found that doses were frequently given up to two hours late. This meant that people did not consistently receive their medicines as prescribed, placing them at risk of increased Parkinson’s symptoms and potentially impacting the effective management of their condition.

Some people required food and fluids to be thickened due to the risk of choking. We found that thickening agents were not stored securely and were accessible to people. This meant there was a risk that these products could be taken inappropriately or by mistake, which placed people at risk of harm.

Some people were prescribed medicines to be taken ‘when required’ (PRN). However, a review of the care records for six people showed that there were no protocols in place to guide staff on when and how these medicines should be administered, in line with the provider’s medicines policy. For example, one person had two different PRN laxatives prescribed to manage the symptoms of constipation. Both medicines had variable doses to allow flexibility in managing this changeable condition; however, there was no guidance in place to support staff to administer either medicine. This meant that people may not always receive these medicines consistently or at the time they were required.

Some people were prescribed variable dose medicines, however care plans lacked detail and were not person-centred to support the safe and effective management of these medicines. During our inspection, we found that a person prescribed a variable dose of a benzodiazepine had received an additional dose which was not in line with the prescriber’s directions. This occurred due to the way the directions and dosing had been entered onto the provider’s electronic medicines administration (eMAR) system. The overdose was not identified or escalated by staff until the time of our inspection. This meant medicines were not always being managed safely or always administered in line with prescribers’ directions.

Some people were prescribed insulin for diabetes, however care plans to support the safe use of this medicine were insufficient. For example, one person’s diabetes care plan did not include their individual blood glucose target ranges or clear guidance on the actions staff should take in response to low or consecutive high readings. As a result, staff were not able to reliably recognise when blood glucose levels were outside safe parameters or respond appropriately. This increased the risk of delayed intervention, poor blood glucose control, and avoidable harm such as hypoglycaemia or sustained hyperglycaemia.
We found some creams in people’s bedrooms did not have legible prescription labels on them and some were not dated when opened. This meant the provider could not be assured people received their medicines safely and as prescribed.

The provider was completing medicines audits, but these audits failed to identify the issues that we found during our inspection.