Swan Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.This is the first assessment for this newly registered service. This key question has been rated Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

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

This service scored 32 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs. Care plans were not always in place to accurately describe changes in need. For example, we reviewed 1 person’s care records and found they were missing care plans for daily life and lifestyle, death and dying, emotional support, maintaining a safe environment, medical needs, nutrition and hydration, pain, personal care, sexuality, skin integrity, and sleeping. This meant staff did not have the relevant information needed to provide person-centred care. Daily care notes were task orientated and did not consider quality of life. The manager told us they were aware of this and were seeking to ensure they were more fully personalised going forwards.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity. Whilst staff understood how to escalate concerns to external professionals, this did not always translate into longer term positive outcomes due to issues with record-keeping and monitoring. This meant root causes might not always be identified and acted upon, to ensure continuity and joined-up care. A staff member said, “If something like one of our residents (people) had a fall then they need an ambulance, then we have to phone 111 and we call them and record and report.” However, 1 relative told us their relative had collapsed, stating, “A paramedic later told me that [person] had a UTI (urinary tract infection); I had not known.” However, we did receive positive comments staff communicated well with external partners. For example, 1 professional who works with the service told us, “Swan Care Home staff have demonstrated good communication and are very responsive.”

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. A statement of purpose was available for people, which set out the provider’s commitment to meeting people’s accessibility needs when providing information. There was also a policy on how the service should meet the Accessible Information Standard. However, despite this, information was not always communicated to people in an accessible way. This included a lack of involvement for people who were unable to communicate verbally with words. The manager had started to re-draft communication care plans, which were more positively worded. For example, 1 person’s care plan showed, ‘When I’m tired, upset or in pain, my speech can become harder to follow. I know what I want to say, but the words don’t come out right, and people sometimes misunderstand me.” Staff needed more training to understand how to ensure they could follow these plans in practice, and for changes to be embedded and sustained.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result. A process was in place for responding to complaints, and we received feedback relatives knew how to complain if required. A relative told us, “I know who to complain to, there is a complaint book and a special e-mail address.” However, complaints were not well managed, and there was a lack of formal, professional response to concerns raised. For example, we saw 1 incident where a relative who expressed dissatisfaction with the care provided had been told to, “Grow up”, rather than following the provider’s complaints policy and procedure. We received feedback there were no relative’s meetings, and input and views about the running of the service were not routinely sought from family members.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it. Reasonable adjustments were not made to ensure equity in access relating to people’s protected characteristics, such as physical disability. For example, at the time of our inspection we found the shared bathroom downstairs was out of order, as the bathtub was broken. There were multiple hazards in the environment which could cause injury to people navigating the building, and a lack of clear signage to help people orientate themselves. This meant the provider failed to address communication barriers and did not operate a dementia-friendly or accessible premises. In addition, people living in the service were vulnerable due to their age and frailty.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this. The provider failed to take proactive action to reduce barriers to care and treatment, including where people lived with low mood as a result of their dementia or other health conditions, to reduce the risk of social isolation and to promote good self-esteem and wellbeing. We reviewed 1 person’s care plan which showed they experienced hallucinations and low mood. The care plan stated, ‘[Person] needs to be reassured a lot that what [they are] telling you was just a vision or a dream. [Person] has become quite verbally aggressive and rude at times and will need support and understanding.’ This framed the person’s distress as rudeness, providing reduced opportunity to have the same experience and outcomes as others without this healthcare condition.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. People, including those receiving palliative care, did not have holistic end of life care plans showing how they would like to be looked after if very unwell. This meant there was no record of personalised comfort measures so staff could meet people’s needs. For example, 1 person’s care plan stated, ‘Staff should be aware that [person] does not have DNACPR in place and nothing has been discussed as to what [person] would like yet.’ We received negative feedback from multiple people’s relatives about end-of-life care.