Swanton House Care Centre Also known as 1-126608129

On this page

• 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 good. At this assessment we rated the key question as 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. We have identified a breach of regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a clear ethos and supported staff through a development and training programme to work within the company’s ethos which was based on a culture of transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider understood the challenges and the needs of people and their communities.

Whilst we identified some concerns these concerns were concentrated on one unit which had a number of issues but was moving forward under the direction of a new unit manager.

Evidence of learning following incidents was being embedded in the service and discussed with staff to help ensure lessons were learnt but not all risks had been identified and actioned at the time of our assessment and recording and communication across the whole site needed improving but this had been recognised and steps taken to improve communication.

Whilst we judged most people received good outcomes of care we were concerned about how the principles of Right support, right care, right culture were being followed to ensure people received a good quality safe service due to the lack of effective recording and ensuring people had clearly recorded goals, objectives, aspirations and circles of support. This would enable staff to support people better in line with their needs and wishes and help staff to promote people’s experiences and take a proactive approach to informed risk taking.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation.

Leaders had the skills, knowledge, experience, and credibility to lead effectively, and did so with integrity, openness, and honesty. The oversight of the site as a whole was lacking and we were not always able to see how one audit fed into another or the underpinning evidence. Some of the issues we identified had not been identified by the provider but were responded to quickly and effectively. The registered manager was keen to consider continuous improvements for the service and ongoing development for staff.

The service had a long-standing registered manager who was completing appropriate studies in higher management courses. Registered nurses and unit managers and team leaders supported the individual units, and each unit had a core group of staff. Relatives confirmed that there were familiar staff when they visited who knew their family members needs well. Nurses and team leaders told us they received enhanced training to enable them to complete their role and there were staff champions across the organisation.

People and staff felt they could speak up and that their voice would be heard. There were systems in place to seek and act on feedback which enabled people and staff to formally be consulted about the service they received and improvements they would like made.

Whilst resident, relative and staff meetings were in place participation was low and we could not always see actions taken to address feedback. Surveys sent out for feedback did not provide enough feedback to be a representative survey. However, we were told by relatives that staff were responsive and concerns where possible were addressed immediately mitigating the need to make a formal complaint. Where there was no relative involvement and a person lacked capacity IMCAs (Independent Mental Capacity Advocates) had been appointed to represent the person. Regular multi-disciplinary discussions and reviews helped to ensure a person’s needs were reviewed and their wishes known.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We found an inclusive and fair culture where for most part staff trusted their leaders and felt able to raise issues. Shifts were planned in advance and helped to ensure staff had a work life balance. Sickness policies ensured staff were supported and there were effective recruitment processes and induction and ongoing support for staff. Staff recognition awards were given for long service and exemplary practice.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s systems for monitoring and improving quality and mitigating risk were not effectively implemented.We identified concerns relating to risk assessment and planning, learning from incidents, supporting people to have full and active lives and how their care needs were assessed and monitored.

People living in different parts of the service experienced different outcomes and quality of care provisions. Whilst some people had a positive experience, this was not the case for everyone. The governance systems had failed to identify this. During our assessment we had some concern about risk management, documentation and whether adequate mitigation was in place. We were also concerned that incidents were not always reported both internally or externally or that the associated risk had been properly evaluated. Whilst people were sometimes admitted to hospital, we found hospital passports and care plans lacked some essential and accurate information which could result in people receiving the wrong care or increasing risks to people. We found the environment was mostly well maintained but we were concerned about the management and support offered to people with epilepsy and we identified potential ligature risks. Whilst the service had an internal trainer to enable them to support staff to manage people who displayed distressed behaviours, we were concerned that one trainer on site was insufficient with their other duties. Clear evidence of lessons learnt or effective debriefings following most incidents were not provided. Staff told us informal processes The lack of recording around antecedents, actual behaviour and consequences did not assure us that staff were properly monitoring people’s behaviour or considering factors which could increase the risk of avoidable harm.

Given the size of the site and the complexity of people's needs we did not consider the dependency tool and associated documents like the individual fire risk assessments to accurately reflect the level of people's needs which might ensure people were funded correctly and be entitled to additional support. We also found the models of care whilst mostly safe, quite generic, and not reflecting the individual needs and interests of people using the service. Again, due to the site size and level of need we found communication and consultation with staff and people using the service could be improved upon.

We found the registered manager and regional manager responsive to immediate and ongoing feedback. As a response they have already told us actions they have taken to address our concerns which includes a review of people’s base line behaviours, a review of the environment, risk assessments and care plans have been updated, and a daily meeting has been incorporated into the routine so heads of departments can catch up and focus on actual and emerging risks.

The provider did understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners or collaborate for improvement.

Feedback from other partners was limited but the feedback we received was positive and the service was highly regarded. We identified concerns regarding Holly Court, but health care professionals said this was an improving picture. Families had mostly praise for the service and said their family members were settled. Local authority feedback was good. Information sharing required improvement particularly around the accuracy of records.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did actively contribute to safe, effective practice and research.

The provider’s history showed continuous learning, and development. However, we did not identify much innovation or the use of technology to support people’s independence. The delivery of care was provided by a consistent group of staff, and this continuity helped people feel safe and settled. Management oversight helped ensure people received good outcomes of care but areas of concern we identified had not been fully identified by the provider but addressed immediately.