Silverjen Limited

The inspection was prompted by concerns raised relating to safe care and treatment and staffing levels: we conducted a focused inspection of the key questions Safe and Well-Led to assess these risks. The location was previously rated Requires Improvement in December 2025. This has now changed to Inadequate following our inspection. We identified 4 breaches of legal regulation in relation to safe care and treatment, safeguarding people from abuse and neglect, good governance and safe staffing.

We found people were receiving unsafe care, which placed them at greater risk of harm or deteriorating health: risks were poorly managed with people having complex health or care needs that staff were unaware of. There was a lack of detailed records about people’s health and care needs, and an absence of guidance to inform staff how to provide care safely.

There were insufficient staff to ensure people had their needs met safely: we found multiple instances of significantly delayed calls, and multiple instances of staff not staying for the amount of time they should: this impacted people’s safety. There was a poor level of staff training and competence: staff training had not been prioritised by the provider, and staff supported people without having the right skills or knowledge to do so.

Leadership was inadequate: the provider and registered manager had limited understanding of the needs of people being supported and had not identified the serious and widespread risks identified at this inspection. Governance and quality monitoring of people’s care, undertaken by the provider were poor: when areas of improvements had been identified by them or their staff, they had not taken action or ensured sufficient improvements were made.

Documentation on how staff should support people was inadequate, and records of care did not clearly evidence how people were being supported in a way that met their needs or reflected best practices, including management of medicines and incidents. We found that medications had been administered in an unsafe way by staff who were not sufficiently knowledgeable on how to do so and there was inadequate guidance in place to ensure people were only receiving medication when they needed to.

People could not be assured they would be safe from harm or abuse. When the provider identified that people were at risk of harm from staff or from incidents, they had not taken action to protect people, and this meant people remained at ongoing risk of abuse. Incidents were not consistently learned from, and safeguarding incidents were not always appropriately reported in line with the providers legal responsibilities.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service was not reflecting this guidance, and people were not treated with respect or as individuals.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. This service has been placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.