Silverdale 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 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 provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 36 (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 promote a positive, person-centred culture underpinned by a clear and shared vision, values and strategy. There was a continued failure to embed a culture based on transparency, equality, equity and respect for human rights.

During the previous inspection, concerns were identified regarding the culture of care for people with a learning disability. At this inspection, these concerns remained. The provider had not embedded the principles of ‘Right support, Right care, Right culture’, and oversight of this group was ineffective.

This resulted in a significant impact on people. There were repeated incidents of distress which had not been effectively reviewed or addressed, leading to ongoing risks to people’s safety and wellbeing. The lack of action to understand and respond to these incidents contributed to an unsettled environment for others living in the service, particularly older people in the nursing home.

Staff told us they did not feel competent or confident in supporting 1 person who experienced distressed behaviour. Incidents had resulted in harm to staff, yet these were not consistently followed by debriefs or reflective learning. This demonstrated a culture where staff were not adequately supported or equipped, which further impacted on the quality-of-care people received.

Despite these concerns, staff remained committed to their roles. They told us they worked well together as a team, supported one another and continued to escalate concerns about people’s health and wellbeing appropriately.

Not all leaders demonstrated a full understanding of the context in which care, treatment and support were delivered. They did not consistently embody or promote the values and culture of the organisation. While staff expressed confidence in the registered manager, concerns remained regarding leadership oversight and governance within the service.

Quality assurance systems were in place, including audits of care tasks. These identified areas for improvement and were discussed with staff. However, governance systems were not consistently effective. For example, incidents of distress, which were clearly recorded within the provider’s systems, were not routinely reviewed or analysed. This meant opportunities to identify patterns, learn lessons and improve care were missed, which impacted people’s safety and wellbeing.

Following feedback during the inspection, the provider took action to introduce improved systems for reviewing incidents.

Despite these concerns, staff described the registered manager as approachable and supportive. One staff member said, “The registered manager is wonderful. We can approach them at any time.”

The provider did not consistently promote a positive and open culture in which staff felt able to speak up and be assured concerns would be listened to and acted upon.

Whilst some staff reported feeling confident to raise concerns and were aware of the organisation’s whistleblowing procedures, this was not reflected across the staff team. One staff member told us, “If we see any poor practice we can raise this with the registered manager, we have all read the whistleblowing policy.”

However, other staff gave mixed feedback. Some staff told us they found it difficult to manage situations where people using the service became distressed, including experiencing incidents of physical assault, and did not feel adequately supported in these instances. This indicated staff did not always feel fully able to raise concerns or feel confident concerns would lead to effective support and action.

The provider promoted an inclusive and fair culture and demonstrated it valued diversity within the workforce. However, sufficient action had not always been taken following incidents to ensure all staff felt respected, supported and treated fairly in their roles.

Staff told us they generally felt supported and were able to access regular supervision and guidance. One staff member said, “I receive regular supervision and support, I feel very supported.”

However, we identified concerns relating to staff wellbeing following incidents involving people who became distressed. Records showed not all incidents had been reviewed with the staff involved, meaning opportunities to provide support, reflection and learning were missed. This did not fully support a culture where staff felt consistently valued and protected.

The provider considered staff wellbeing during recruitment. For example, new staff completed health questionnaires to identify any additional support needs, which helped ensure reasonable adjustments could be considered and implemented where required.

The provider did not have effective systems of governance, accountability or oversight to ensure safe, high‑quality and sustainable care. Responsibilities and lines of accountability were unclear, and leaders did not consistently act on or share information about risk.

Governance systems were not robust and failed to identify, monitor and mitigate risks. Safeguarding oversight was ineffective, and systems to monitor incidents lacked analysis to identify patterns, trends or emerging risks. As a result, the provider could not ensure appropriate action had been taken to protect people from harm.

Improvements were needed in safe recruitment and medicines management. The provider responded to feedback by introducing new monitoring systems.

Staff described challenges in managing behaviours, with support needs exceeding the service’s capacity. One staff member said, “[Person] is not correctly placed [at the home] because the staff cannot manage their behaviours.” Another staff member described how incidents often required multiple staff to respond safely. This reflected poor planning, risk management and oversight, placing people and staff at risk of harm.

Opportunities to learn from incidents were missed. Debriefs and reflective practice were not routinely undertaken, and learning was not shared. Improvements were not embedded, leaving risks unaddressed and contributing to repeated incidents.

Overall, ineffective governance and oversight meant the provider could not demonstrate care was safe, risks were managed, or continuous improvement was achieved.

The provider did not always work effectively in partnership with other organisations to ensure people received seamless, joined-up care. Systems and practice did not consistently support the sharing of information or collaborative working to drive improvement.

While some professionals provided positive feedback about their interactions with the service, this was not consistent. The provider had not always shared concerns appropriately or escalated safeguarding issues to relevant partners. This limited external oversight and reduced opportunities for timely, coordinated responses to risks.

As a result, opportunities to work collaboratively, improve outcomes and ensure people’s safety and wellbeing were not always maximised.

The provider did not consistently demonstrate a culture of continuous learning, improvement and innovation across the service.

Improvements had been made since the last inspection, including developments in healthcare monitoring and aspects of the environment. However, lessons had not been effectively learned in relation to supporting people with a learning disability in line with the principles of ‘Right Support, Right Care, Right Culture’.

This meant care was not always delivered in a way which met people’s individual needs or promoted positive outcomes. Concerns remained regarding the suitability of 1 person’s placement, as their needs required a model of care aligned with ‘Right Support, Right Care, Right Culture’, which was not consistently achieved.

Although the provider was responsive to feedback during the inspection and implemented new systems, these were not yet embedded or demonstrated to be effective. We shared our concerns with the provider and the person’s funding authority to ensure appropriate review and oversight.

As a result, opportunities to drive sustained improvement and innovation were not fully realised, impacting on people’s care and experiences.