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Archived: Swanborough House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 16 January 2020

About the service

Swanborough House is a residential care home providing personal care and accommodation for up to 31 people with acquired brain injuries. At the time of the inspection the service was supporting 31 people. Accommodation is provided on two upper floors with the ground floor dedicated to communal and therapy spaces.

People’s experience of using this service and what we found

The environment of the service was poor and there had been a lack of investment in the building. Carpets were thread bare in places and heavily stained. The lounge was single glazed, notably cool in areas and its roof was leaking. In people’s bedrooms we found examples of torn carpets, damaged furniture, and tired décor. Relative’s told us, “It is pretty past it, it is showing it's age” and “The building is not the best, it does not sell itself on how it looks but the people are the priority”.

The service’s quality assurance systems had identified these issues but there had been a lack of appropriate action and investment by the providers previous leadership to make the necessary improvements.

There have been significant changes to the leadership of the provided since our last inspection. The previous chief executive departed in May 2019 and replaced by a new senior leadership team.

The new leadership team had begun making improvements to the service’s environment prior to our inspection. The kitchens and laundry had been refurbished and dangerous areas of glassing replaced. A bathroom was being significantly upgraded and a bedroom redecorated during our inspection. In addition, an extensive remodelling of the service was planned to include an extension and upgrading of all bedrooms. Staff told us, “We are having all these fantastic improvements now which we have been asking for years and years. It has changed a lot” and “There has been a lot of improvements.”

The providers failure to invest in the service had impacted on staff morale and culture. During the lunchtime meal people had to wait while staff collected their lunches, and this adversely impacted on one person’s desert options. In addition, a failure to support one person to achieve a recognised goal had caused them significant frustration.

The registered manager was well respected by staff and relatives. They told us, “[The registered manager] is very nice, you can ask her anything”, “The manager is very supportive, she is very very helpful” and “I have a great deal of respect for the [Registered manager].”

Staff had been recruited safely and appropriate induction training was provided. All staff received regular supervision and training updates to ensure they had the skills necessary to meet people’s support needs. We have made a recommendation in relation to specific training for staff on how to support people when anxious.

People told us they were well cared for and staff responded promptly to people requests for assistance.

Care plans were accurate and up to date. They provided staff with enough guidance to ensure people’s needs were met. Staff said, “I think there is enough information in the care plan and they are working to make them more detailed.” While relatives told us, “I get a copy of the care plan sent to me every month and I go through it and sign to say I am happy with it. It is accurate.”

People were able to engage with a range of activities and therapies each day. People told us, “The entertainment is good, there is activities every day” and “I get to choose to go or not, there is a good range [of activities].” There was minibus available to enable people to access the community and visit local sites of interest.


We have identified breaches in relation to the environment of the service, the providers quality assurance process and failures to consistently respect people’s dignity.

Please see the action we have told the provider to take at the end of this report.

Rating at last inspection

At our previous inspectio

Inspection areas



Updated 16 January 2020

The service was safe.

Details are in our safe findings below.


Requires improvement

Updated 16 January 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 16 January 2020

The service was not entirely caring.

Details are in our caring findings below.



Updated 16 January 2020

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 16 January 2020

The service was not always well-led.

Details are in our well-led findings below.