Swallowtail Place

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity, and respect. This is the first assessment for this service. This key question has been rated Requires Improvement. This meant people did not always feel well-supported, cared for, or treated with dignity and respect. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 40 (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 did not always treat people with kindness, empathy, and compassion, and respected their privacy and dignity. We received some negative feedback from people on agency staff that had been working at the service, with one person saying, “They don’t seem to know us”. Staff told us that they took staff agency staff round with them and introduced them to people. We did not see that the provider carried out any competency checks on agency staff.

However, we received positive feedback from people who used the service and their relatives on the caring nature of staff. One person told us, “They are caring, all of them. They always ask how I am and is there anything they can do for me”. While a relative told us, “They are just always there for you”. People told us staff respected their privacy and dignity.

The provider did not always treat people as individuals or make sure people’s care, support, and treatment met their needs and preferences. They did not always consider people’s strengths, abilities, aspirations, and protected characteristics. People’s care plans held conflicting information regarding their current abilities, strengths, and communication needs. Goals and aspirations were not always recorded. This meant we could not be assured that staff could be guided by people’s care plans to support them effectively. We found people’s care plans referenced other unrelated individuals, where parts of another person’s care plan had been copied over entirely from another person.

The provider did not always promote people’s independence, so people knew their rights and had choice and control over their own care, treatment, and wellbeing. Staff had a good understanding of how to promote Independence and choice. One staff member told us, “I believe passionately in client-led care, although I have a task list, the clients will tell you what they want”. We received positive feedback from people and their relatives, one person said, “I can cancel or change my care calls as I want to”. While another person said, “They ask me what I need doing and have set tasks. They always ask if anything else needs doing”. Care plans were not always clear on how much support people required and what tasks people could carry out independently. Whilst those able to communicate could share what they needed we remained concerned about how care was being provided to people who found communication more difficult or had no-one else to advocate for them on their behalf.

The provider did not always demonstrate how they listen to or understand people’s needs, views, and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern, or distress. Health issues were not acted upon promptly, and people were at risk of harm. There was no separation between answering emergency call bells and completing care rounds, which meant care calls were often late or call bels not answered. We received feedback from staff that they did not have enough time to support people and felt rushed. One staff member told us, “Alarm bells are going off a lot, I am constantly being pulled away from the person I am with to answer the bells, going back and forth like a ping pong ball”. Staff also raised concerns around staffing levels, especially in the afternoons, and if there was an emergency. One staff member told us, “I was praying no one calls their bell, we need another staff member, mainly a senior who can deal with an emergency”.We received mixed feedback from people. One person told us, “Sometimes I have to wait for staff to answer the bell; this takes longer at night.”

The provider did not care about or promote the well-being of their staff. They did not support or enable staff to deliver person-centred care. We found there had been inconsistent management and leadership in the service since February 2025, which had negatively influenced staff morale. One person said, “Staff morale is low, people used to love coming to work, and everyone was happy, engaged, and motivated. Now it is low and upset, people have been in tears”.

There had been a lack of staff supervision and appraisals being completed, and staff felt they had been overlooked by the provider. Staff told us they felt a lot of pressure had been put on them by the provider to complete training in a very short space of time, but they had not been given time off to do this, and neither had their workload been adjusted accordingly. Staff spoke positively about their colleagues and how they had been supportive of each other. They also spoke positively about their roles and the care they provided.