Swan House

Updated 14 May 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 3 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Swan House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the

quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. There is a manager in post who is in the process of registering with us.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since our last inspection, including notifications the provider had sent to us and information we have received from members of the public and the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with 8 people and 7 relatives or friends. We spoke with the manager, the deputy manager, the nurse, the housekeeper and 7 care staff. We looked at the care records for 18 people. We checked the care people received matched the information in their records. We looked at records relating to the management of the service, including audits carried out within the service and staff recruitment checks.

After the inspection we continued to received information from concern from the local authority and member of the public including relatives.

Updated 14 May 2024

About the service

Swan House is a care home providing personal care for up to 45 people. The service provides support to people who are both residential and nursing care. Some of the people in the home are living with dementia. People have access to their own bedroom along with communal spaces including lounges. The home is split between 2 floors, lower is residential and the upper is nursing care. At the time of our inspection 40 people were living in the home.

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

The service was not safe. Risks to people were not monitored or reviewed after incidents or changes occurred and people were not protected from harm. Care plans and risk assessments lacked detailed, and actions implemented to keep people safe were not followed. People did not always receive pain relief when needed and medicines were not always safely managed, as stock checks were inaccurate, and bottles opened were not dated.

There were not enough suitably recruited staff to support people. The lack of leadership in the home meant the staff were not safely deployed, and they did not have the training, skills or knowledge to support people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Safeguarding procedures were in place and followed to report concerns there was a lack of accountability in the home with regards to this.

The systems in place to monitor the home, the care people received were not effective as they had failed to identify concerns. There was lack of learning lessons as action had not been taken since the last inspection to make the necessary improvements to comply with a warning notice . The home was not well managed. There was a lack of understanding from staff on their roles and there was no leadership in the home, placing people at risk.

The home was clean on the day of our inspection. Signage had been used to support people living with dementia.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service was requires improvements (Published 13 November 2023)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

You can see what action we have asked the provider to take at the end of this full report.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to how people’s risks were managed, staffing and their training, how people consented to their care, the lack of governance and leadership in the home. The diets that people received.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.