Silverdale Nursing Home

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• 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 remained 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 governance at the service. This was because the provider failed to ensure their model of care complied with current learning disability guidance and systems in place to check the quality of the service failed to identify where actions were needed.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager told us staff morale was positive from what they’d seen. They acknowledged there had been a difficult time when they first took over and changes were made but they seemed to be moving forward. Staff told us they had not been involved in determining the future direction of the home. Staff raised concerns regarding the training they had received prior to supporting people with learning disabilities and were unhappy they had not been consulted with regarding the change of direction of the home. Staff also told us they were aware that some colleagues were unsure whether they would continue working at the home due to this.

The provider had not submitted an updated statement of purpose to CQC at the start of the assessment process. This meant the existing statement of purpose did not reflect they were now supporting people with primary needs of learning disabilities. The provider told us they had updated this and submitted it during the assessment process. Systems in place were not adequate to ensure staff were communicated with regarding the change in the direction of the home and their plans to support people with learning disabilities.

Staff told us they were not always sure when one of the management team was in and available which could be frustrating for them. However, they did tell us management were usually available via telephone. The manager and nominated individual confirmed they did not always work set hours due to trying to cover days and nights to get a better feel for the home. They told us they would implement systems so staff had more information regarding when they would be working going forward. This was implemented during the course of the assessment process. Staff told us they did not always feel people living at the home were treated equally by management and some people they supported were given more time and attention than others. The manager told us their experience was in supporting people with learning disabilities but whilst they didn’t have clinical qualifications, they had vast experience in supporting people with complex needs. Staff told us they did not have any direct clinical leadership at the home and whilst they did feel well supported in other ways, they would benefit from additional clinical oversight. Leaders were not always sufficiently knowledgeable around the 'Right Support, Right Care, Right Culture' guidance which underpins providing support to people with learning disabilities. However, they were passionate about improving care at the home and meeting the needs of the people who lived there. Where staff had raised concerns regarding supporting people with learning disabilities, the provider did not always adequately respond to improve staff confidence and the quality of care provided to people.

The manager had significant experience as a registered manager, primarily in homes for people with learning disabilities. However, neither the manager or the nominated individual had a clinical background. Despite this, there was no clinical lead in post or systems in place for clinical oversight for nurses who were working at the home which may have placed people at risk of harm in the event any clinical concerns had arisen. Whilst nursing staff were confident and knowledgeable, no arrangements had been made for any clinical supervision or oversight. Furthermore, despite leaders having experience in supporting people with learning disabilities, systems in place had failed to ensure that the home was compliant with current guidance when supporting people with learning disabilities. We did not find any evidence of management meeting minutes. Where we identified concerns that were from a time period prior to the new manager being in post, we were sometimes unable to gather evidence due to the informality of processes in place and lack of robust documentation. Whilst the new manager was trying to implement positive changes at the home, they had not yet had the time to address all of the actions that required addressing.

Staff felt able to speak up if they had concerns. Staff were not concerned about any repercussions if they raised concerns but were not always confident concerns would be appropriately acted on. Staff were aware of how to whistle blow if needed and were confident on blowing the whistle on poor practice. The manager was open and honest about the actions that they had been identified when they started employment at the home and what required addressing to improve the quality of care provided at the home.

A whistle blowing policy was in place. Policies were available to staff in the nurses and manager’s office and staff knew where to find them.

The manager told us they had a diverse workforce and respected their diversity. The manager told us they considered the English language skills of staff where English is not their first language to ensure they are able to meet people’s needs safely. The manager also told us they were striving to become more flexible so they could support staff who required different working hours due to their family commitments. Staff did not always feel empowered and valued in respect to decision making around the home. Staff told us they were unhappy that decisions had been made to support people with learning disabilities without consultation with them beforehand as they did not feel like they had adequate knowledge to support them effectively.

Systems were in place to enable staff to work flexibly around their family commitments. Staff were required to complete a health questionnaire on recruitment in order for adjustments to be made if needed to enable them to do their role. Systems in place to promote the wellbeing of the workforce were not always adequate. For example, payment for break times had been removed which had impacted staff morale. Where staff were recruited where English was not their first language, the manager had implemented systems to check they had sufficient language skills and competence to meet people’s needs safely and effectively.

The manager told us they were reviewing audit processes as they did not think they were always effective. The manager told us that previous audits implemented prior to them commencing work at the home had sometimes been a tick box exercise and it was not always clear what was being reviewed. However, audit reviews had not yet taken place. Staff did not always understand their roles and responsibilities. Staff told us they did not always know when the manager and/or nominated individual would be in work so they were not always sure who was responsible for the running of the home on a day to day basis. However, they did tell us the manager and nominated individual were contactable by telephone if they needed them.

Systems in place to check the quality of the service were not always sufficient to identify errors so necessary action could be taken. Some of the audits were a tick box process to confirm the check had been done but it wasn’t clear what was being checked. Therefore, audits had not always picked up concerns such as inconsistencies in people’s care documentation or where running counts weren’t being undertaken for some medicines. Audits of accidents and incidents had also failed to identify where safeguarding referrals had not been submitted when needed. The new manager had implemented an action plan which identified some actions that were required but they had not yet had time to address many of the actions. Systems in place to address actions identified as part of external quality audits failed to ensure actions were taken in a timely manner. Actions identified by the local authority had also failed to be addressed in a reasonable timescale. Systems in place to ensure statutory notifications were submitted to CQC were insufficient. We found examples where statutory notifications had not been submitted for allegations of abuse and no action had been taken to notify CQC that the provider was supporting people with learning disabilities and to request the addition of the appropriate service user band until this was raised during the site visit. A business continuity plan was in place.

People were supported to access professionals including health professionals and social workers. People told us the provider was proactive in ensuring they received support from professionals they required. People and relatives were involved in review meetings with health and social care professionals. However, the provider did not always address concerns identified by partners in a timely manner to ensure the quality of care people received was improved and actions were addressed where needed. For example, where the local authority quality improvement team implemented a quality improvement plan, there was slow progress in addressing concerns despite multiple meetings regarding this.

The nominated individual and manager acknowledged they had not addressed a number of actions identified by the local authority during their quality visits. They told us this was due to them being relatively new in post. However, the provider had still been slow to address the actions that had been identified as concerns in order to evidence improvements at the home. The manager told us the home had positive relationships with health and social care partners and worked closely with them. The manager told us how they received regular visits from the GP surgery and worked in collaboration to improve care for people at the home. Staff told us how they worked alongside other professionals to ensure people received the care they needed.

Partners told us the provider worked collaboratively with them to improve care provided to people. Health professionals told us the provider effectively communicated concerns in a timely manner and followed their recommendations. However, the local authority told us the provider had not been timely in addressing actions that had been identified during quality visits which had impacted on the ability to evidence improvement at the home.

Residents and relatives meetings had not been frequent but the manager told us they were looking to reimplement more frequent meetings going forward. During the assessment process, a relatives' meeting took place at the home which the manager told us had been positive. Systems in place to ensure effective information sharing with local authority safeguarding teams and CQC were not sufficiently robust to ensure referrals and notifications were always submitted. Systems in place to implement learning from quality visits were not always sufficient to ensure actions were taken proactively and learning shared in a timely manner. Regular meetings were in place with the local GP surgery to discuss any health concerns regarding people at the home. Review meetings took place when needed.

The manager told us there were feedback forms readily available for visiting relatives should they wish to provide feedback. The manager told us they listened to what was fed back and took action if needed. The manager also told us they had reintroduced relative meetings to enable them to obtain further feedback from relatives. The manager told us they had received some calls from members of the public commending staff when people had been supported out in the community so they have fed this back to reinforce positive practice. The manager also told us that where things went wrong, they reviewed people’s care plans and fed back any changes to staff in order to learn from where things had gone wrong. Staff told us they did not always have team meetings to share learning but learning tended to be shared through handover and communication between staff. Staff told us insufficient action was taken to ensure they felt competent when supporting people with learning disabilities.

The provider used a training matrix but staff were not always up to date with all training. At the time of the site visit, they were in the process of transferring over to a new training system. The new manager had formulated an improvement plan since starting work at the home which identified a high number of actions that required completion. The new manager had started to address this but had not had time to address most of the actions at the time of the site visit. Team meetings were irregular so information was not regularly shared in this forum. Where actions had been identified by the local authority, the provider had been slow to address them to improve the home.