Swindon Intermediate Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service.

This key question has been rated as good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

People felt confident to raise concerns, and staff consistently demonstrated compassion and understanding. Leaders encouraged staff to speak up when things went wrong, promoting openness and accountability.

The service used an electronic reporting system to report incidents, near misses, safeguarding concerns and safety events and staff understood which incidents required reporting and followed established reporting procedures.

Staff recorded and investigated complaints, and they offered apologies and support when harm occurred and met their duty of candour by providing clear explanations to people and families following adverse events.

The service investigated incidents and complaints and used the learning to make changes that improved the quality and safety of care. Leaders shared feedback from investigations with staff through team and clinical governance meetings, supporting shared learning. The service also shared learning from incidents with external organisations where appropriate, supporting wider system learning and safety improvement.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Referral and admission processes ensured that staff received all essential information to assess whether they could meet people’s needs safely.

Staff supported continuity of care through effective handovers, including using structured handover sheets prepared by the referring ward. Staff planned discharges in a timely way and supported safe transfers from the ward to community or residential settings. For example, staff completed discharge summaries on the electronic patient record, sent them electronically to the person’s GP on discharge, and provided a printed copy for the person to take home.

Staff shared transfer of care information with relevant healthcare providers using standardised forms. They fully completed, dated and signed forms, including body maps, summaries of care, and pressure ulcer risk assessments.

Staff involved appropriate health and social care services to support safe discharge and continuity of care, including social care teams, community nurses, GPs and specialist placement staff where required.

Staff completed daily safety checks of specialist equipment. They maintained records that were complete, and they ensured resuscitation equipment remained clean, in date and compliant with portable appliance testing requirements.

Staff of all grades attended regular safety huddles during shifts to share safety‑critical information, and staff understood how to escalate concerns when a person’s condition deteriorated.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Security arrangements protected people from unauthorised access and supported safeguarding. For example, staff secured access to wards by using electronic swipe cards to enter stairwells leading to ward areas. Reception staff controlled visitor access by requiring visitors to report to the main reception and confirm who they were visiting. Staff kept medicine rooms and cleaning cupboards secure with restricted access.

Staff were aware of and followed safeguarding policies, there was a designated safeguarding lead, and staff accessed advice and support when needed. Staff recognised, reported and escalated safeguarding concerns appropriately. Staff demonstrated how they protected people from harassment and discrimination, including those with protected characteristics under the Equality Act.

However, the service had not ensured that all staff had completed mandatory safeguarding training for adults and children that was appropriate to their role, including how to recognise and report abuse. When the current provider took over the inpatient services in April 2025, it reviewed staff training requirements as part of its service development and transition arrangements and identified that not all mandatory safeguarding training had been completed. At the time of our assessment, 98% of staff who required Level 2 adult safeguarding training had completed it; however, only 70% of staff who required Level 3 training had done so. The service had an action plan in place to increase compliance with mandatory training. This included directly contacting relevant staff to support and monitor completion. We also saw evidence within staff appraisal records that outstanding training were discussed.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff ensured emergency equipment was available, well maintained and ready for use.

Staff recognised and responded to deteriorating people. They used the National Early Warning Score 2 (NEWS2) system to identify people who were becoming unwell. Staff recorded NEWS2 scores electronically and took appropriate action in response to changes in condition.

Staff included all key safety information during staff changes and handovers to keep people safe. Staff used safety huddles and handover sheets effectively. Each staff member maintained an up‑to‑date handover sheet with key safety information recorded at the start of each shift.

However, the service did not always work effectively with people to understand and manage risks. This was reflected in a high number of pressure ulcer incidents that leaders identified through their own review of incident data before we assessed the service, which they acted on to strengthen oversight and reduce risk. Nurse managers held clear responsibility for monitoring all pressure ulcers and met regularly with the tissue viability nurse to review cases, and reviewed pressure ulcer data weekly to identify themes and prevent recurrence.

During our assessment, we observed a reduction in reported pressure ulcers in April 2026 compared with December 2025, demonstrating learning from incidents and improved risk management.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts in place to ensure the premises were appropriately maintained. Staff completed health and safety risk assessments and audits and addressed identified risks. For example, they replaced a fire door in the kitchen following assessment findings to improve fire safety. Leaders also implemented, monitored and reviewed a business continuity plan.

Staff knew where to find emergency equipment and how to respond to emergencies. Staff used systems to check resuscitation equipment regularly, ensuring it was fully stocked and ready for use.

Staff ensured they had easy access to emergency alarms, and patients could easily access nurse call systems.

The service provided suitable facilities to meet the needs of patients’ families and ensured it had suitable equipment to support safe patient care.

Staff disposed of clinical waste safely.

People we spoke to said they felt “safe” and had “no worries” about their safety on the ward.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us that staffing levels were not always adequate, which affected their ability to deliver timely care and complete all required tasks.

During our assessment, staff reported staffing pressures across nursing, pharmacy and therapy teams. These pressures reduced capacity, increased workloads and placed additional strain on staff. The service conducted interviews for additional staff during our assessment, and there were ongoing efforts to recruit more staff.

Staff spent significant time completing essential tasks, such as medicines administration, which reduced the time available for other aspects of care and patient interaction. Some people using the service told us that staffing levels limited the time available for activities and rehabilitation. People spoke positively about regular staff, who encouraged them to be independent, but they felt staff could not always provide enough support to help them regain skills.

Leaders did not maintain effective oversight to ensure staff completed mandatory training and remained competent in their roles. Although leaders had systems in place to monitor mandatory training, they did not use these consistently and effectively. During our assessment, staff completed outstanding training, and compliance increased to an overall average of 85%.

The service employed enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide appropriate care and treatment.

The service ensured access to on-call medical support during evenings and weekends.

Leaders produced a weekly flexible workforce report to monitor sickness and staffing levels and identify where additional staff were required to meet enhanced care needs.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff accessed an infection prevention and control (IPC) policy that provided clear guidance on good practice to reduce the risk of healthcare‑associated infections. Staff reported IPC incidents to the IPC committee for review and oversight.

The service used effective systems to assess, manage and reduce infection risks, including responding to outbreaks, and followed national IPC guidance and worked closely with the IPC team to keep people safe.

During our assessment, one ward reported cases of COVID‑19. Staff escalated concerns promptly and managed them in collaboration with IPC leads. Where isolation capacity was limited, the ward manager assessed risks and took proportionate action, including moving a newly admitted person with a respiratory history to a single room. Meeting minutes showed that leaders maintained oversight and shared learning from the outbreak, including reviewing communication processes after a delay in notifying a positive COVID‑19 result.

Staff kept wards visibly clean, and they labelled equipment with in‑date “I am clean” stickers. Cleaning records remained up to date and showed regular cleaning of all areas.

Staff followed IPC principles, including using personal protective equipment correctly, maintaining bare below the elbows, and adhering to hand hygiene guidance. Staff ensured sharps bins were available, correctly labelled, not overfilled, and managed in line with policy.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines.

Staff completed medicines records accurately and kept them up to date.

Staff stored and managed all medicines and prescribing documents safely.

Staff followed national practice to check that patients received the correct medicines when they were admitted or moved between services.

Staff learned from safety alerts and incidents to improve practice.

Staff completed regular medicines training and competency assessments and felt confident in storing, administering and recording medicines.

The service introduced medication safety drop‑in sessions to support staff to use the new electronic medicines system safely and effectively. These sessions focused on key processes, including ordering medicines, sending and receiving tasks, transcribing medicines, completing medicines reviews and safety checks, and raising and flagging medicines‑related concerns.

Staff stored medicines, including controlled drugs, securely and at appropriate temperatures.

Staff recorded and disposed of waste medicines appropriately.