Swallowtail Place

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this service. This key question has been rated inadequate.This meant there were widespread and significant shortfalls in people’s care, support, and outcomes. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 38 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing, and communication needs with them. The provider had not fully assessed people’s changing health needs, which meant people did not get the right support promptly. For example, staff recorded that a person was not eating or drinking and had issues passing urine. However, this was not raised with health professionals, and the person was eventually assessed to be severely dehydrated. The provider took a hands-off approach to contacting people’s doctors and relied on updates from relatives. We did not see a policy around this.One staff member told us that, “People’s needs have changed, and we are slowly becoming a care home. But we do not get any more time to support them.”

The provider did not plan and deliver people’s care and treatment with them, including what was important and mattered to them. People told us their health needs had not been discussed with them. We saw a person’s care plan had been reviewed on 13 November 2025, but the person told us they had not been involved. They told us, “No one from the office has spoken to me about my care plan”. One care plan we reviewed contained information about a different person and did not reflect the needs of the person being assessed. This meant people were at risk of receiving poor care not tailored to their needs.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services. We saw that when the provider did send referrals to other healthcare professionals, these were never sent in a timely manner, meaning people were at continuous risk of harm. Despite this some people and relatives told us the staff worked well and kept them informed of changes. One person told us, “I need to talk as I don’t see anyone, it’s very valuable to me. We laugh; it’s a bonus.”

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice, and control. Staff did not always support people to live healthier lives, or, where possible, reduce their future needs for care and support. Staff recorded changes to people in their daily logs, but records did not demonstrate that concerns were followed through and actioned by the provider. This meant important changes to people’s health and emerging risks remained unresolved and the level of care was not representative of their needs.Despite this staff were seen to offer people verbal choices and encouraged them to be independent. One person told us that, “They (Staff) take the time to make sure I have had a decent meal.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. People’s changing needs had not always been assessed, and staff complained about not having enough time to support people. One staff member told us, “Care changes and takes too long to allocate more time, so we end up missing breaks. It has a knock-on effect on the next calls.”

The provider did not always tell people about their rights regarding consent and did not always respect their rights when delivering care and treatment. The provider had failed to adhere to the Mental Capacity Act 2005, and legal consent for the care and treatment delivered was not consistently in place.The provider did not always complete Mental Capacity Assessments (MCAs) for people, and we could not see if people had consented to care and treatment or lacked capacity. Some people we spoke to told us that they were able to tell the staff what support they needed. One person told us, “I have a way in which I like to be supported, and the regular staff know this. I teach the new ones.”