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Swiss Cottage Care Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 11 September 2021

About the service

Swiss Cottage is a care home providing personal and nursing care to 73 people. Most people were living with some form of dementia, some were receiving end of life care. The service can support up to 85 people.

People’s experience of using this service and what we found

One person’s relative said, “I don’t feel [my family member] is safe.” Another person’s relative told us the same. One member of staff said, “We are pushed to the limit, everyone has their breaking point.” We asked one person if there was enough to do to keep them happy and fulfilled. “No, staff are mostly nice, but they don’t have time.”

People’s safety was not being protected and promoted. Two people living with advanced dementia had left the home when it was not safe for them to so and had gone missing. There were failures in the security of the building and processes in place to alert staff and those in charge this had happened. Staff were not updated, and lessons were not always learnt when this and other incidents had happened before.

When people had potentially experienced harm, robust measures were not followed to promote their safety and rights. Safeguarding alerts and referrals to the local authority were not raised when they should have been. People’s property in the home often went missing. Systems were not effective in securing people’s property.

Staff told us there was not enough staff to always meet people’s care needs. Most falls were unwitnessed by staff. Staff did not respond when fire exit alarms were sounded. Staff did not spend time with people to talk, give them comfort, and promote their mental and emotional well-being. Internally arranged events to promote people’s interests, were not taking place at the home. The environment was not homely or comforting. One relative said, “The home is very clinical, it looks a bit tired.”

There was ineffective leadership at the home. Staff did not feel listened too. When they raised issues with the manager, they said nothing changed. The manager of the home and provider were not effectively testing the quality of the care provided. The manager and provider were not looking at people’s experiences to see if improvements were needed. The manager and provider no longer saw the clear shortfalls in people’s care in terms of promoting people’s safety and seeing what people’s daily lives were really like.

For more details, please see the full report which is on the CQC website at

Rating at last inspection The last rating for this service was good (published on 26 January 2018).

Why we inspected

We received concerns in relation to staffing levels, medicines, people not receiving personal care, staff not responding to a possible head injury, and clothes going missing. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, responsive and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Swiss Cottage on our website at

Inspection areas



Updated 11 September 2021

The service was not safe.

Details are in our safe findings below.



Updated 11 September 2021



Updated 11 September 2021



Updated 11 September 2021

The service was not responsive.

Details are in our responsive findings below.



Updated 11 September 2021

The service was not well-led.

Details are in our well-Led findings below.