Swallowtail Place

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. This is the first assessment for service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not ensure the delivery of high-quality care.The service was in breach of legal regulation in relation to governance at the service.

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 have a clear shared vision, strategy, and culture, which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Whilst the service had aims, objectives, and values in place, these had not been consistently adhered to. The service lacked consistent management in the 12 months prior to our assessment, and we saw a lack of direction and poor culture within the service. Furthermore, recommendations for improvement made by the Local Authority 4 weeks before our assessment had not been fully implemented.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively, or they did not always do so with integrity, openness, and honesty. The registered manager was unable to tell us the baseline needs of people and was unable to demonstrate how care was being provided. They said this was because they were new in post since September 2025. One staff member told us, “I don’t feel like the management is approachable at the moment; I feel like there’s no appreciation.” Following our initial site visit and feedback, the provider put together a leadership team to support the service in getting things right for people.

People did not feel they could speak up and that their voice would be heard. People told us there was now a new manager, but they had months where they had not known whom to go to if they had issues. People did not feel like their complaints were dealt with. One person told us, “I’m diabetic, and I started shaking, and I called my alarm, and nobody came. I reported to the manager and have not yet heard any outcome of the investigation.” Staff told us the manager was approachable but overwhelmed with work.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.Staff had completed equality and diversity training; however, staff told us that concerns raised about being treated fairly and equitably have not been addressed. One staff member told us, “At the moment, staff morale is about as low as it can get.” And “We don’t feel like our concerns are listened to.” Staff told us that they did not feel included in the improvements the provider had started to make following our first feedback. We have told the provider of staff concerns.

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 had a quality assurance system in place, but this was of poor quality and had failed to identify and rectify the concerns found at this assessment or the ones identified by the Local Authority. Not all areas of the service were monitored for quality to drive improvement and where quality monitoring audits were in place, these did not provide assurances that they were robust and meaningful. Furthermore, regulatory requirements had not been met, and the registered manager failed to demonstrate they had the required knowledge in relation to their regulatory responsibilities.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Due to the manager’s lack of understanding of working with other stakeholders to ensure people received safe and effective care, their recommendations had not always been fully implemented. For example, recommendations for improvement which were made by the Local Authority following a quality audit had not been implemented, meaning people were still at risk of harm at the time of this assessment. This placed the people who used the service at risk of receiving unsafe care or care that fell below the required and expected standards.

The provider did not focus on continuous learning, innovation, and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. There was no effective system in place to measure and evaluate the service to ensure its outcomes were consistently positive and safe, and that all reasonable steps had been taken to mitigate risk. The service analysed little data, and where analysis had taken place, this was of poor quality, and we saw little evidence of where it had been used to drive meaningful improvement. For example, staff feedback during a team meeting on suggestions for improvement had not been fully acted upon. We also saw concerns raised on behalf of people who used the service had not been recorded, and there was no evidence to show what action the provider had taken in response and to drive improvement as a result.