CQC report explained · a nursing home
What the CQC found at Silverdale Nursing Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found kind, personalised care, but medicines checks and management systems were not reliable enough.
This was an unannounced follow-up inspection. Inspectors visited on 1 November 2022, with inspection activity continuing until 9 November. They spoke with people living at the home, relatives, staff, a health professional and managers. They also checked infection prevention and control.
The home had improved since its previous inspection, when it was rated Inadequate and placed in Special Measures. Inspectors found the home was cleaner, staffing was more consistent, risks were better managed and care plans were more personalised. The home was no longer in breach of regulations and was no longer in Special Measures.
However, some important systems still needed improvement. Medicines records were not always followed up quickly, some as-required medicine instructions did not match prescriptions, staff supervision had not started regularly, and people and relatives were not always asked for feedback or kept informed.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. This means the home had made progress, but inspectors could not yet be confident that all improvements were fully established.
Kind and respectful care
People were treated with kindness, dignity and respect. Staff supported independence and involved people in decisions about their care.
“People were supported by staff who were kind and caring and treated them with respect.” from the report
Personalised care
Care plans reflected people's individual needs and preferences. Staff followed this guidance and supported people to make choices.
“The new documentation was person centred and reflected people's preferences and their individual needs and this was followed by staff.” from the report
Improved staffing
Recruitment checks had improved and the home had reduced its use of agency staff. This gave people more continuity with staff who knew them.
“The provider had reduced the use of agency staff at the home which meant people were supported by staff who knew them well.” from the report
Cleaner environment
The home had been refurbished and cleaning standards had improved. Inspectors found changes that reduced the risk of infection spreading.
“We found the home was clean and hygienic and cleaning was undertaken throughout the day of inspection.” from the report
Activities and communication
People were supported to take part in activities they chose. Staff adapted communication for people with sensory or cognitive needs.
“On the day of inspection, we saw people engaging in ball games, quizzes, colouring and a musical session with a singer.” from the report
Medicine checks
seriousStaff did not always investigate missed medicine signatures promptly. Some instructions for as-required medicines did not match the prescriptions, although inspectors found no evidence of harm.
“Staff did not always immediately identify where signatures had been missed. This meant there was a delay in investigating the reason for the missed signature.” from the report
Staff supervision
needs fixingRegular supervision had been planned but had not started. Inspectors also noted that newly recruited staff were not always initially up to date with mandatory training.
“Plans were in place to commence regular staff supervision, but this had not yet started.” from the report
Feedback and communication
needs fixingPeople and relatives were not always asked for their views or told about management changes. The manager had started introducing feedback forms and a newsletter.
“Relatives told us they were not informed about managerial changes at the home and some told us they did not know who the current manager was.” from the report
Incomplete improvement records
needs fixingThe home's audits identified actions, but records did not always show when those actions had been completed. This made it harder to see whether improvements were being followed through.
“Audit systems had been implemented to check the quality of the service. These were effective in identifying actions that needed to be taken but documentation was not always completed in full.” from the report
Equality needs
minorAssessments recorded people's religions but did not always explore whether they needed support with religious needs. Inspectors found no evidence that this had affected people.
“People's needs in relation to their protected characteristics under the Equality Act 2010 were not always considered.” from the report
- 01How do you now check and quickly investigate missed medicine signatures?
- 02How do you make sure as-required medicine protocols always match each person's prescription?
- 03Have regular staff supervision meetings now started, and how do you check staff competence?
- 04How are people and relatives asked for feedback and kept informed about changes at the home?
- 05How do your audits record that identified actions have been completed?
This was an unannounced follow-up inspection after the previous Inadequate rating, and it also included checks on infection prevention and control; the report does not describe it as the previous comprehensive inspection. This explanation was written from the published report of 5 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2022
Rated Inadequate and placed in special measures; inspectors found serious failures affecting safety, care, dignity and management.
This was an unannounced inspection over two days. Inspectors spoke with people living at the home, relatives, staff and visiting health professionals. They reviewed care records, medicines records and staff files, and checked infection control.
Inspectors found widespread problems. People were at risk from unsafe medicines, poor infection control, missed safeguarding referrals, weak risk assessments and delayed healthcare. The home was unclean and poorly maintained. Some people had lost weight without enough action being taken.
People were not consistently treated with dignity or involved in decisions about their care. Care plans were out of date, activities were not personalised and complaints were not properly handled. Staff training, recruitment checks and management oversight were also inadequate.
All five areas were rated Inadequate: Safe, Effective, Caring, Responsive and Well-led. The last inspection had rated the service Good in all five areas. The provider took some immediate action during the inspection, but inspectors said significant improvement was still needed.
Immediate fire safety action
The provider took immediate steps to improve fire safety for agency staff and to make sure trained staff were allocated to shifts.
“The provider immediately implemented a fire safety induction for agency staff at the home and all staff were provided with fire safety cue cards” from the report
Action plan started
Consultants had begun a detailed action plan focused on improving outcomes. Inspectors said it was too early to see significant changes.
“The consultants had identified a thorough action plan which they had started to work through.” from the report
Some activities took place
Inspectors saw baking and painting during the inspection, although these activities were not tailored to each person's interests.
“We observed some activities including baking and painting being undertaken during the inspection by an activities member of staff.” from the report
People were at risk of harm
seriousSafeguarding referrals were not always made, risks were not managed and wound care was missed. One person's dressings were not changed for 20 days despite the care plan.
“This placed them at significant risk of harm.” from the report
Unsafe medicines
seriousInspectors found an incorrect insulin dose, insulin stored outside the fridge for too long, unsafe fridge temperatures and incomplete medicine records.
“The provider had failed to ensure that medicines were stored and administered safely.” from the report
Unlawful restrictions
seriousSome people were deprived of their liberty without the required legal arrangements. Bed rails and covert medicines were used without the necessary capacity assessments or best interests decisions.
“This meant people were being unlawfully restricted.” from the report
Nutrition and weight loss
seriousPeople had unintended weight loss without enough action being taken. Food records lacked detail and dietary preferences were not always followed.
“People had experienced unintended weight loss. Where they had experienced weight loss, no action had been taken to address this which placed people at risk of harm.” from the report
Poor dignity and personal care
needs fixingStaff did not always speak respectfully or protect privacy. Inspectors saw a person's dressings changed with the door open and no screen.
“This meant the person could be seen by anyone who walked through the corridor which was not dignified.” from the report
- 01What changes have been made to prevent medicine errors, including insulin storage, dosage checks and medicine record checks?
- 02How are safeguarding concerns, accidents, incidents and risks now recorded, reviewed and referred?
- 03How do you make sure staff and agency workers have the training, induction and supervision needed for people's nursing, dementia and dietary needs?
- 04What action has been taken to monitor and respond to unintended weight loss and to provide food that follows each person's dietary needs and preferences?
- 05How are people now involved in care planning, capacity assessments, best interests decisions, activities and end of life discussions?
The inspection began as a focused review of Safe, Effective and Well-led, but concerns found during the visit led CQC to complete a comprehensive inspection covering all five key questions. This explanation was written from the published report of 24 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Silverdale Nursing Home
6 rated inspections over 6 years: the service has improved, from Inadequate to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- August 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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