Swan Care Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Inadequate

• Responsive

  Inadequate

• Well-led

  Inadequate

Our view of the service

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.

People's experience of this service

Whilst some people expressed general satisfaction with their care, our assessment found care did not meet the expected standards. One relative said, “It’s basic. The building is old; it’s a former pub, it's small. What matters is what works for your relative. It's safe, [person] is clean and fed and it's meeting a lot of [person’s] needs.” We received some comments people had limited ways to spend their time and did not always have their own clothing in their bedroom. A relative said, “I went through the wardrobe and drawers and found items that did not belong to [person]. Clothes are not named.”

Some relatives were worried about the safety of people living at the service. A relative told us, “When we take [person] to the conservatory, the doors are locked, and they are a fire exit.” Another relative told us, “[Person] is often left in [their] room for hours before being attended to, even after ringing the [nurse call] bell.” And, “I rang the bell 4 times to get [person] out of bed, [person] was hungry and thirsty.” We made safeguarding referrals to the local authority following feedback, to ensure people were kept safe from neglect and harm.

We were told there had been a change of staff team, following the new provider taking over Swan Care Home in May 2025. There were mixed views about this, but largely positive about the new staff team and the new manager, who were operating in difficult circumstances without effective provider oversight and support. One person’s relative said, “The new manager has a lovely relationship with [person] who has still got a bit of banter about [them].” Another relative said, “I saw a care worker who has been there a while, directing a new care worker.” However, another relative said, “There are not enough staff, and those present seem insufficiently trained.”