Silverways Nursing Home

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

This meant the service 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 was in breach of legal regulation in relation to good governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

There was a lack of oversight from the management team to ensure people’s needs were met in accordance with their care plans. We received mixed feedback from staff. Some did not always feel supported by management, and they did not always feel they could bring their worries to them. However, some staff felt supported. One staff members said, “I don’t feel like our voice is being heard. I got told by management that if you have any problems or concerns to come to them. Then when you do you get a reputation for being a troublemaker or a moaner […] even if they are legitimate concerns. So, I know staff tend now not to bother.”

Another staff member told us, “I generally feel supported and appreciated at Silverways Nursing Home. The service recognises staff contributions through initiatives such as ‘Employee of the Month’ awards and regular team discussions. While support is generally good, there are times when communication or feedback could be further strengthened.”

Staff took part in regular team meetings and had supervisions. The service had an up-to-date Equality, Diversity and Inclusion policy in place.

Not all leaders understood the context in which the service 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.

We received mixed feedback from staff regarding the leadership of the service and the accessibility of the management team. Some staff reported feeling well supported and described the management team as approachable. However, others told us they felt unsupported. Comments included, “I know the registered manager and I find them very approachable. They absolutely model inclusive behaviour. I get all the support I need in a very caring way and I have also seen her be compassionate and caring to all of our ladies and gentlemen and also all her staff”, “[There is] lack of support from the management”, and “The registered manager appears to be unapproachable and I do not feel the management practices an all inclusive policy.”

The management of the service introduced various incentives for staff, such as “Managers Magical Moments” to celebrate the great work that went on and started Employee of the month awards.

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

Staff told us they knew how to whistle blow, and report concerns to external organisations such as CQC and the local authority if necessary. However, we received mixed feedback from staff. Some felt they could approach the management of the service and some staff felt they could not.

One staff member said, “I do feel able to speak up about any issues, and the Registered Manager always encourages staff to do this. We have daily ten-minute meetings where anyone can voice a concern or make a suggestion about how improvements can be made.”

Another staff member told us, “I do not always feel able to speak up at work, as I feel my concerns are not always listened to or acted upon. […] As a result, I have felt discouraged from raising further concerns, as I do not feel encouraged that my voice will be heard going forward.”

The registered manager and provider were aware of their responsibilities and the importance of supporting staff to speak up. The provider had an up-to-date safeguarding policy.

The service 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 work for them.

Whilst some staff felt the management team were inclusive, others told us they felt not all staff were given the same opportunities. Comments included, “Our workplace is inclusive, there is no discrimination and there are equal opportunities. […] My own religious background has made me aware of religious and cultural differences, and I have recently undertaken the Equality, Diversity and Inclusion training”, “I feel the home is inclusive”, “I feel that the workplace is generally inclusive and staff are not openly discriminated against. However, I do not feel there are always equal opportunities for everyone, as there appears to be some favouritism”, and “I don’t feel it is inclusive or equal opportunities for all.”

The registered manager introduced an employee of the month award. The service had a suggestion box for people and staff to use. Staff had equality and diversity training.

The service 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.

Governance systems in place were not always robust. The registered manager did not have an effective overview of incidents and accidents. The provider did not always submit notifications of relevant events to CQC. However, the provider made the necessary notifications retrospectively. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them.

The provider did not have appropriate oversight of medicines management at the service. As a result, people did not always receive their medicines as prescribed and 1 person was overdosed on their medicine.

We found some food items, such as jams, various drinks and condiments, were not always dated when opened. This meant it was not possible to determine how long these items had been in use or whether they were still within a safe period for consumption. Systems and processes in place did not identify safe food practices were not always followed.

The systems in place to monitor people’s weight, diet requirements, mattress pumps settings and repositioning records were not robust and did not identify the shortfalls found during this inspection.

In response to our inspection feedback the registered manager and provider started to make changes and improvements to the way the service was run. The improvements made needed to be embedded into practice and sustained.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Records showed the service regularly communicated with a wide range of health and social care professionals as required to meet people’s needs.

Health and social care professionals did not raise any concerns about partnership working with the service.

The service 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 registered manager nominated staff to champion roles to improve oversight for various aspects of people’s lives at the service. This included a weight and cream champions. These roles were new and had not yet been fully embedded, and further time was needed for staff to monitor outcomes and evidence improvements.

Our inspection found widespread shortfalls which were not identified or addressed through the provider’s previous quality management audits or systems which evidenced learning and improvement was not embedded into practice.