Swan Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. This is the first assessment for this newly registered service. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to consent and capacity, staffing, and person-centred care.

This service scored 33 (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 make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. We could not be assured people’s individual needs had been appropriately assessed and fully understood, or that the service could meet them. There was a lack of information in respect of people’s wellbeing needs, communication needs, hopes, ambitions, goals, interests and how to support and promote independence. There was limited evidence to show how people had been involved in the assessment process, and relatives told us they had no involvement in care planning. The new manager was in the process of revising care plans, but this was still in the early stages of development at the time of our inspection. This meant the provider could not yet demonstrate the impact of any changes or improvements.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. The service did not follow national best practice guidance for dementia care, and the environment was not dementia-friendly. A relative told us, “It's not a specialist dementia home. There are people here on funded places and sometimes it's too far for [relatives] to visit. It sometimes feels a bit rough and ready.” A staff member said, “I had a dementia training in my previous care home, not here. [Management] are doing more training for the staff.” There were no pictorial menus to help people decide what they wanted to eat, and we did not see people having input into the food choices on offer. For example, on the day of our inspection we saw people were not initially offered a choice for lunch, and the options for dinner written on the board were, ‘Sandwiches, pasta, cherry cola.’ Despite this, some people told us they were satisfied with meal provision. For example, 1 relative said, “[Person] has put on weight, as [person] eats a cooked lunch.”

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services. Whilst we received some positive feedback from other stakeholders, this was impacted by the wider issues and concerns identified during our inspection which had not been effectively identified and addressed by the service. This included shortfalls in written assessments, care planning and documented monitoring of people’s care and treatment. This meant we could not be assured information shared with others would enable people to receive care in line with their assessed needs. However, we were told some staff could explain people’s needs verbally. A professional who works with the service told us, “Calling the home has not been an issue. I believe that I am always able to speak to a staff member who is aware of the patient, and they can relay appropriate information to me about their care.” Improvement was needed to ensure this was properly documented by staff, to support effective team working.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support. People had access to healthcare professional support, including the chiropodist, the dentist and the GP. A relative said, “A couple of days ago because [person] has an infection and has been put on antibiotics, the doctor was called in.” However, people were not empowered and supported to manage their own health, care and wellbeing by staff who fully understood their individual needs and preferences. For example, there were limited trips outside of the care home for people to access activity and exercise beneficial for health and wellbeing, to reduce deterioration and retain strength and independence. After the inspection, the provider confirmed they were seeking physiotherapy input for people living at the service.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. We found some people’s care notes were incomplete, lacked detail or were illegible. We found there was no record of any meaningful leisure time to show how people’s quality of life had been considered. For example, we reviewed daily care notes for 1 person and within a 2-week period there was only 1 entry for 45 minutes of ‘general activity in the lounge’. At 6pm on the day of our site visit, inspectors observed a person who appeared to be sitting in the same position and in the same chair all day. We saw the person required the support of 2 staff to move with a hoist due to limited mobility. A review of their daily care notes showed the last entry had been made at 10.33am, and there were no records of any care or support provided since this time. This meant the provider could not demonstrate their care needs had been met, as monitoring and recording processes were poor and ineffective.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. We saw some people were subject to restrictive practice by staff, even where they had the capacity to make decisions by themselves. For other people who may not have the capacity to consent to all aspects of their care and treatment, leaders had failed to complete mental capacity assessments for all applicable decisions. For example, 1 person’s care plan stated they did not have capacity to take their own medicines so staff should organise this for them, but no mental capacity assessment was in place to show how this conclusion had been reached. Our observations showed institutionalised care delivery had been normalised, and people were not treated as unique individuals or empowered to have as much choice and control as possible over their own lives. A person’s relative told us, “I was very happy with the old staff; they were very inclusive. The new ones tend to be instructing.”