Swan Care Home

Date of Assessment: 18 May 2026 to 9 June 2026. The service is a residential care home providing support to up to 21 people, including those living with dementia. At the time of our inspection, there were 10 people living at Swan Care Home, as the local authority had placed an embargo on any new admissions due to quality and safety concerns.

We carried out this inspection to follow up on enforcement action. At the last inspection we found 9 breaches of regulations, the service was rated Inadequate and placed into special measures. At this inspection we found 8 continued breaches relating to person-centred care, dignity and respect, consent, risk management, safeguarding, premises, governance, and staffing. Improvements had been made to recruitment practice, and the service was no longer in breach in this area. ​

Governance and oversight measures were extremely poor, and the provider had failed to rectify widespread and significant concerns identified by the CQC. The provider had failed to work with multiple managers or consultants since taking over the service in May 2025. A fourth new manager had just started at the time of our inspection. People did not receive person-centred, dignified care, and were placed at the potential risk of avoidable harm. We made multiple referrals to help keep people safe during the inspection, including to the local authority safeguarding team and to the fire service.

In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Date of Assessment: 11 November 2025 to 1 December 2025. The service is a residential care home providing support to up to 21 people, including those living with dementia. This is the first inspection of this service, which was first registered with the CQC in May 2025. We carried out this assessment in response to concerns we had received about the service.

We found 9 breaches of regulations relating to person-centred care, dignity and respect, consent, risk management, safeguarding, premises, governance, staffing and recruitment. ​

We identified significant and widespread concerns at this assessment, which had not been identified and mitigated by the provider through their own governance systems. People did not receive holistic, person-centred care, and were not always treated with dignity and respect. Legal requirements relating to capacity and consent were not consistently in place, and systems for safeguarding were ineffective, placing people at risk of harm. Risks to people were not identified and mitigated, including in relation to the premises and environment, infection control, food hygiene, medicines, and the management of specific healthcare conditions. Due to provider failures in recruitment, induction, training and supervision processes, staff did not have the support and knowledge they needed to fully meet people’s needs.

In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.