Silverdale 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 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 provider was previously in breach of the legal regulation in relation to safe staffing. Enough improvement had been made, and the provider was no longer in breach of this regulation. However, the provider was in breach of the legal regulation relating to safeguarding people from abuse and harm.

This service scored 38 (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 demonstrate a proactive or positive culture of safety.

Systems to support learning from incidents were ineffective. The registered manager did not consistently investigate or report safety events, limiting opportunities to identify risks, implement improvements, and prevent recurrence. As a result, lessons were not routinely learned or embedded into practice.

Although staff completed incident records using ABC (Antecedent, Behaviour, Consequence) charts, these were not regularly reviewed or used to inform reflective practice, care planning, or risk management. There was no evidence of structured debriefs following incidents, and learning was not shared effectively with staff or relevant professionals. This meant repeated episodes of distress were not sufficiently analysed, and opportunities to reduce risks and improve outcomes for people were missed. Staff told us they did not always feel equipped to support 1 person during periods of distress, indicating a lack of organisational learning and support.

Despite these concerns, people told us they felt safe living in the home. A relative also spoke positively about the care provided, describing their family member as being well supported by staff.

The provider did not always work effectively in partnership with people and other professionals to make sure care was safe and well organised. While systems were in place to monitor some aspects of people’s physical health, oversight of other areas of safety was not always effective or used consistently.

Some aspects of people’s health were monitored well, including nutrition, weight and support with moving safely. However, care for people living with diabetes was not always well managed. Care plans and risk assessments did not clearly explain how staff should monitor and support people with this condition to help keep them safe.

Risks linked to people’s behaviours were not always well assessed, monitored or managed. For example, the impact of 1 person’s behaviour on others had not been fully explored or reduced. This meant people were not always supported in a way which promoted a safe, and person-centred environment.

Feedback from professionals about working with the service was mixed. Some described staff as responsive and proactive. Others said there were delays in communication and their advice was not always acted on quickly, meaning people did not always receive timely, coordinated care.

The provider did not work effectively with people and relevant partners to identify, report, and respond to safeguarding concerns. Safeguarding systems were not robust, and incidents were not always recognised or escalated in accordance with best practice principles.

During the inspection, we identified multiple incidents involving physical threats and emotional distress which had not been referred to the local safeguarding authority. These incidents met the threshold for external reporting but had not been escalated appropriately. The registered manager told us the reporting system did not alert them to these events and confirmed they had not routinely reviewed the associated records. However, staff described these incidents as occurring regularly, and records were clearly documented and accessible within the provider’s systems, indicating a lack of effective oversight.

Following inspection feedback, the provider reviewed several incidents and submitted safeguarding referrals in some cases. However, further incidents involving prolonged periods of physical and verbal threats were not referred because the registered manager did not consider these to meet the safeguarding threshold. Due to the seriousness of these concerns, we shared this information with the local safeguarding authority.

This lack of oversight, combined with a failure to recognise and act on potential safeguarding concerns, meant people were not consistently protected from the risk of harm.

Despite these concerns, staff demonstrated an understanding of safeguarding responsibilities and described how they would report concerns. Relatives also told us they felt their family members were safe living in the home.

The provider did not always work effectively with people to understand, assess and manage risks in a safe and coordinated way. Although a positive approach to risk-taking was encouraged, this was not always supported by strong risk management practices, meaning risks were not consistently reduced.

We identified concerns around how people were supported during periods of distress. Staff told us 2 people could not safely be in the same room because 1 person repeatedly directed behaviours towards the other. When this happened, staff described increased distress among other people in communal areas, which created a disruptive and unsettled environment. This showed risks were not managed in a way which protected the safety and wellbeing of everyone using the service.

There was limited evidence showing how people were meaningfully involved in planning how risks should be managed, or how strategies were regularly reviewed to reduce the impact on others. A lack of coordinated approaches meant opportunities to create safer and more inclusive environments were missed.

Despite these concerns, people told us they were able to make choices about their day-to-day lives. One person spoke positively about activities they enjoyed. During the inspection, we observed staff respecting people’s preferences and encouraging involvement in activities, showing some person-centred practice was in place.

The provider did not always effectively identify, assess, and control risks within the care environment. Systems to ensure the safety of equipment, facilities, and the premises were not consistently robust, which meant risks to people and others were not always mitigated in a timely way.

At the start of the inspection, we identified the provider’s external fire risk assessment was out of date. This meant the provider did not have up-to-date assurance regarding fire safety risks within the service. Following our feedback, the provider acted promptly and arranged for a new fire risk assessment to be completed during the inspection. The external assessor shared initial findings which indicated there were no immediate risks to people using the service.

We also identified environmental risks within the home. The water temperature from a tap in a staff toilet, which was open and accessible, was excessively hot, posing a risk of scalding. In addition, radiators with metal coverings were found to be hot to the touch, presenting a potential burn risk. The provider responded to these concerns by taking immediate action, including arranging for the staff toilet to be secured and fitting wooden covers to radiators to reduce the risk of harm.

The home environment was generally clean and free from malodour, although some areas required refurbishment. During the second day of the inspection, we observed improvements to the outdoor areas, including the development of a newly renovated space for people and relatives to use, demonstrating responsiveness to environmental concerns.

Relatives provided positive feedback regarding the safe use of equipment. One relative described how staff supported their family member with moving and handling tasks in a careful and appropriate manner.

The provider ensured enough staff were on duty to meet people’s needs, including those with a learning disability or autistic people. However, recruitment and training required improvement.

Staff completed online positive behaviour support training but did not feel confident managing distress or responding to incidents involving physical behaviour. There had been numerous incidents, including staff assaults, which raised concerns over the risks to staff. Following feedback, the provider arranged further training and planned to develop staff skills to support people safely.

Recruitment processes were not consistently effective. Gaps in employment histories were found, and some checks had not been reviewed for long periods. The provider’s policy did not clearly set out expectations for Disclosure and Barring Service (DBS) re-checks. One staff member had a Criminal Records Bureau (CRB) check completed prior to DBS introduction, with no evidence of review or risk assessment. Following feedback, the provider reviewed recruitment records and strengthened oversight.

Despite these concerns, people and relatives spoke positively about staff. People said staff responded when needed, and relatives described staff as kind and caring.

The provider assessed and managed risks relating to infection prevention and control. Effective systems were in place to detect, prevent, and control the spread of infection, supporting a clean and safe environment for people, staff, and visitors.

Relatives and people using the service told us the home was clean and well maintained. People described how their personal spaces were kept tidy, and some were involved in maintaining their own rooms, promoting independence where appropriate. During the inspection, we observed staff carrying out cleaning duties and found the environment to be visibly clean and hygienic throughout.

Although some areas of the home required refurbishment, there was no impact on cleanliness or infection control standards. The provider demonstrated awareness of environmental improvements needed and shared plans to address these areas.

Quality assurance systems, including regular cleaning schedules and audits, were in place to monitor standards of hygiene and cleanliness. These systems supported the provider to maintain appropriate infection prevention and control practices.

The provider did not always ensure medicines were stored, monitored and recorded safely.

Skin patch medicines were not always managed safely. Records for 1 person included gaps and did not show how patches were regularly moved to different areas of skin, increasing the risk of irritation and reduced effectiveness. For another person using a weekly pain patch, there were no daily checks to confirm it remained in place, so staff could not be sure the medicine was working as intended.

Medicines requiring refrigeration were not monitored in line with best practice. Although temperatures were recorded each day, maximum and minimum readings were not taken, so safe storage could not be fully assured.

Despite these concerns, people said they received medicines in a respectful way and at the right times. We observed people receiving their medicines in a dignified manner. Relatives described medicines being adapted to meet people’s needs, including support with swallowing. Controlled medicines were managed safely, with clear records in place. Where medicines were given covertly, this had been reviewed and agreed with relevant healthcare professionals.