Swan Care Home

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect. This is the first assessment for this newly registered service. This key question has been rated Inadequate. This meant people were not treated with compassion and there were breaches of dignity; staff caring attitudes had significant shortfalls.

The service was in breach of legal regulation in relation to person-centred care and dignity and respect.

This service scored 25 (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 demonstrate, through their approach to running the service, that they prioritised people being treated with kindness, empathy and compassion, or with respect to their privacy and dignity. Staff did not treat colleagues from other organisations with kindness and respect. Our observations found a lack of dignity and respect. Records and observations showed language used about people which was disrespectful and undignified. This included describing people as ‘double handers’, ‘soiled’, ‘rude’, ‘aggressive’ and 'lashing out’. Staff spoke about continence support in shared spaces where they could be overheard. On the day of our inspection site visit, there were 3 male staff members and only 1 female staff member, which meant people could not have the choice to be supported with their personal care by a staff member of the same gender, if this was their preference. Bedding and the environment was poor and worn and did not uphold the dignity of those living there and show them they were valued and respected. For example, people were offered drinks from worn coloured plastic beakers. This failed to uphold people’s dignity. We received mixed feedback from relatives, who generally agreed staff were kind and supportive, and the new manager was trying to make changes. However, others raised serious concerns which we shared with the safeguarding team. For example, 1 relative told us, “[Person] is very well cared for; happy, clean and eats well.” However, another relative described finding a person in torn clothing, stating, “I don't think [person] is safe from [pressure ulcers] from negligence, or from staff.” The provider told us they were committed to continued investment in the service, including the environment, and would address the need for person-centred language.

The provider did not demonstrate how they were ensuring people were treated as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics. Although some people’s interests were recorded, staff lacked information to guide them on how to treat people as individuals, as well as training in key areas such as how to communicate with people living with dementia. Our observations showed people did not have any meaningful engagement with staff, and there was little to do all day except for sit in the living room facing the television. Some people had items placed next to them, such as jigsaw puzzles, but were unable to participate without staff support, which was not recognised and provided. A person’s relative said, “The activities are in a cupboard, I have never seen them used.” And “[Person] would like to go to church, [person] loves singing hymns. It is the opposite. This request cannot be met. Music is never turned on; it’s always the TV.” However, another relative said, “[Person] also has dementia, however [staff] always take magazines and newspapers for [person] to read.” Bedrooms were bland, and lacked personalisation to show people’s interests, hobbies, life histories and individual decorative tastes.

The provider did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing. People were not encouraged and empowered to meet their own aims, ambitions and goals. During our visit, we observed 1 person remain alone in their room all day, before being supported to bed before 7pm. This was despite it being recorded in their care plan they preferred to go to bed at 9.30-10pm. We heard staff encouraging people in the lounge to also go to bed at 7pm, reflecting institutionalised practice which did not respect or demonstrate people’s choices. Observations and records reflected restrictive practice by some staff who had not had the correct training and support from the provider. For example, we heard 1 staff member tell a person, “That’s not nice [person], go back to your room.” We saw some positive feedback about 1 person who had been supported on a recent trip to the pub. However, this was not people’s experience more widely.

The provider did not demonstrate they were listening to or understanding people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress. Although staff were well meaning, there was no specific training on how to reassure people expressing distress, or any evidence of staff de-briefs to support learning and continuous improvement in practice. During our site visit we heard a person who was crying and confused, telling staff, “I don’t know where I am.” The staff member told the person, “You are in a care home. You can sit down. Good girl, be quiet please.” Whilst the intention was to be reassuring, this was infantilising as it treated the person in a way which did not respect their maturity and experience, and we heard the person continue to be upset. We saw evidence the new manager had begun to re-write care plans, describing people in a more positive and respectful way and setting out more clearly how staff should meet their immediate needs.

The provider did not demonstrate how they care about or promote the wellbeing of their staff. They did not support or enable staff to deliver person-centred care. The manager had only been in post for 5 weeks and did not have any effective support due to the unexpected absence of the provider’s Nominated Individual. Workforce wellbeing was not proactively considered, with staff working multiple 12-hour shifts in a row. Staff told us they had limited breaks, with some staff telling inspectors they only had a 20-minute break throughout the whole day. This placed them at risk of stress and fatigue related errors. The manager told us they had raised this with the provider, but was not responsible for rotas or able to access them. We received feedback people felt the new staff team were trying their best in difficult circumstances. A relative said, “The new staff are better.” Another person’s relative said, “The manager is very efficient. I'm impressed by the [staff] who work there. They are very kind and compassionate.” However, even where staff sought to provide a good level of care, they were not able to meet people’s individual needs due to systemic provider failures.