Date of assessment: 5 August – 27 September 2025 Silverjen Limited is a homecare agency registered to provide personal care to people in their homes. The service is registered to support people living with dementia, eating disorders, mental health conditions, physical disabilities, sensory impairments, substance misuse problems and people with a learning disability and/or autistic people. CQC only inspects where people receive personal care. This helps with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of the assessment, 91 people were receiving personal care. As part of this assessment, we spoke with 10 people who used the service and 8 relatives. As the service is registered to provide care to people with a learning disability and/or autistic people, we assessed the service against ‘Right support, right care, right culture’ (RSRCRC) guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. During this latest assessment, we found the service was able to demonstrate how it was meeting the underpinning principles of RSRCRC in the areas we reviewed. We conducted this assessment to follow up on the breaches identified during the last inspection and to address information received from the local authority. The last inspection of the service identified breaches in relation to good governance, fit and proper persons employed, and the need for consent (report published 30 September 2022). At this assessment, we found that the provider was no longer in breach of regulations; however, there were still areas for improvement. We have reported on these in the safe and well-led sections of this focused assessment. Staff were recruited safely and received training relevant to their roles, including in relation to supporting people with a learning disability and/or autistic people. However, there were areas of improvement in relation to staff supervision. The governance system generally identified shortfalls; however, further improvement was needed to ensure it consistently picked up missing information in care records. While most of the care plans we reviewed were detailed, person-centred and provided clear guidance for staff, we found that 3 people’s care records were not always accurate. The provider acknowledged this and took immediate action, sending us updated records. However, there were missed opportunities to identify and address these issues sooner, as the governance systems had been slow to respond. The impact on people was minimal because managers and staff knew individuals well and took the time to understand their needs.
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Silverjen Limited was rated Requires Improvement overall, with breaches of Regulations 11, 17 and 19 relating to MCA compliance, governance and recruitment checks. While caring and responsive aspects remained Good and people reported feeling safe and well-treated, governance shortfalls, weak medicines auditing, last-minute rotas and a manager-coached response to inspectors undermined leadership.
Concerns (8)
criticalGovernance: “The lack of robust governance system and processes as well as management oversight was a breach of Regulation 17”
criticalConsent / capacity: “The failure to follow the principles of the Mental Capacity Act 2005 was a breach of Regulation 11”
criticalStaff competency: “registered manager was not always meeting the requirements of Schedule 3... breach of Regulation 19”
moderateMedication management: “we found gaps in people's MARs and a lack of double signatures on handwritten prescription entries, meaning the audits were not being robustly carried out”
moderateRecord keeping: “Some care plans we requested could not be found on the system and two people's care plans had been stored under an incorrect name.”
moderateLeadership: “staff shared with us a message sent out by the service with a list of possible questions we may ask them, together with the responses they should give”
moderateSupervision / appraisal: “staff told us they did not feel supported or valued. They had raised some concerns during supervision with the registered manager.”
moderateStaffing levels: “two live-in care staff worked 12-hour shifts without another carer arriving to give them a break”
Strengths
· People felt safe with care staff and risks were identified with mitigation guidance in care plans
· Staff treated people with dignity, respect and encouraged independence
· People reported staff arrived on time, stayed the full duration and there were no missed calls
· Good infection control practices with plenty of PPE available
· Effective partnership working with GPs, district nurses, hospices and multi-disciplinary teams
Quality-Statement breakdown (21)
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choicesNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care; End of life care and supportNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Duty of candourNot rated
well-led: Engaging and involving people, public and staff; promoting a positive cultureNot rated
well-led: Continuous learning and improving care; working in partnership with othersNot rated