Swallowtail Place

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs. This is the first assessment for this service. This key question has been rated inadequate. This meant services were not planned or delivered in ways that met people’s needs. The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 36 (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 make sure people were at the centre of their care and treatment choices, and they did not always work in partnership with people to decide how to respond to any relevant changes in people’s needs. People told us the staff were good, and one person said, “We found that as people’s needs changed, the care provided was not adjusted promptly.” One family member told us that when their relative refused care, there were no proactive steps to support them. They told us, “The area I havethe biggest disappointment with was their personal hygiene. It was poor; they hadn’t done hands, face wash, or body wash for a long time."

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. We found a lack of continuity as care notes did not document critical information, and care plans did not reflect people’s complete needs and failed to ensure staff had all the information they needed to ensure individualised care was always delivered. For example, one person’s care plan had been updated on 10 November 2025 to include new equipment. But staff were not provided with any training to support the person or given information on what it meant to their daily life, and care planning even if they were not directly needed to support this aspect of their care.

The provider did not supply appropriate, accurate, and up-to-date information in formats that were tailored to individual needs. We found the provider had a system of charging people for extra calls beyond the peace of mindfee they paid weekly to have staff answer their care calls when they pressed their pendant alarms. However, people had not been provided information regarding this charge and when it was applicable, leading to fear for some people. A relative told us, “When dad fell in the night, mum managed to get him up and back into bed; she didn’t call the bell because she thought she would get charged.”

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result. People told us that there had hardly been any management presence in the past year, and when the new manager started, they stayed mostly in the office. This meant people did not always have anyone senior to raise concerns with, beyond the care staff.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it. People told us sometimes they had to wait for their care, and no explanation was offered. Rotas were not always correct, and people did not receive the staff they had been allocated. One person told us, “I get a rota; it isn’t always adhered to. They change the person and time without telling me. It’s annoying. I don’t know why they can’t tell me. It makes a difference to me as I’m in a chair and I must wait for them to come.”

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. We received a mixed response from people about their experience. One person told us, “Since I’ve been here, I’ve got a different life completely. The carers are brilliant.” However, another person told us.” “Before I went on holiday (September), I was very ill. I rang my alarm, and nobody came.”

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their lives. The provider’s records did not show that they were having conversations with people as their needs changed. A relative told us that they dealt with the social worker concerning their family member. We could not see information was always shared, and the manager did not seem to have the information to hand about people’s imminent and future needs. Care plans did not contain information on end-of-life planning, and critical paperwork like respect forms were not always accessible to staff. This place people and staff at risk of not knowing about or adhering to important decisions which may have been agreed.