Swan Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to risk management including medicines, the premises and environment, staffing, recruitment and safeguarding.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and a realistic understanding of the quality and safety of care people needed. They did not respond or take proactive action in relation to safety and did not effectively investigate or report safety events. They had not identified and embedded good practice and safety events were not always recognised, appropriately escalated and learned from to support staff development. The inspection was prompted in part by notification of incidents following which people using the service sustained serious injuries. These incidents are subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of these incidents. However, the information shared with CQC about these incidents indicated potential concerns about the management of risk relating to skin integrity and falls. This inspection examined those risks, and found continued concerns in these areas. Whilst staff could tell us how to respond to an incident, there was no meaningful overview or analysis of accidents, incidents, falls or safeguarding to reduce the risk of reoccurrence. For example, we were told the cause of bruising for 1 person had not been reported or investigated. Although we received some feedback people felt safe at Swan Care Home, we were not assured all incidents were appropriately logged or action taken to stop it from happening again.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Whilst we received some positive feedback from professionals who work with the service, we found care records were not always complete and up-to-date. This could cause confusion about people’s care needs when they moved between services. There was a new manager in post, who was working to build connections to support safe pathways of care. A professional told us, “I find the communication with the team has been improving since the change-over and we are building a closer working relationship.” During the inspection process, the local authority placed an embargo on any new people transitioning into the service, in response to the widespread safety and quality concerns identified. The provider also confirmed they would not accept any new admissions, including from people who privately fund their own care, whilst they made the necessary improvements.

The provider did not ensure their staff team worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. During our inspection site visit, we found 3 staff members and 1 of their relatives living in a flat on the third floor of the care home, with the only access through the care home itself. Leadership were unable to show this had been risk assessed or what the formal arrangements in place were to protect those living in the care home or the individuals living there. The manager told us they did not know all of the names and identities of those living on site, but confirmed the provider had told them 1 individual did not have a Disclosure Baring Service check (to confirm there are no concerns working with vulnerable people). We were informed although this individual was not on the rota or staff list, they had already completed a night shift delivering care. This had not been recognised as a serious safeguarding issue. As a result, we raised an urgent safeguarding alert to the local authority before leaving the premises, due to the potential risks arising from this practice. The provider later confirmed 1 individual was not authorised to be on site and had been asked to immediately leave. This had not been independently identified through safeguarding systems and processes, or by the leadership team. The provider confirmed the on-site accommodation would be decommissioned going forwards.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Whilst risk assessments were in place in some areas, they were not sufficiently detailed, consistently understood by staff and/or followed in practice. For example, there were no specific risk assessments for healthcare conditions such as Parkinson’s Disease. We also found records were inconsistent, such as stating a person ‘could’ and ‘could not’ walk independently. Critical safety records such as how to prepare thickened fluids for a person at risk of choking, or repositioning records for a person at risk of pressure damage were not always accurate or legible, placing people at potential risk of avoidable harm. Staff did not have specific training in how to reduce risks to people. We provided a detailed overview of our concerns to the local authority safeguarding team, and all people living at the care home received a new social worker review to check their wellbeing and safety.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Inspectors found multiple hazards in the environment which had not been identified and addressed, placing people at serious risk of harm. This included cleaning chemicals accessible in unlocked rooms, an uncovered hot electric radiator which was rusted and degraded, a leaking conservatory roof causing mould, and an unrestricted upstairs window. The hallways were cluttered with large equipment, wet floor signs, cleaning items and laundry baskets, placing people at risk with a known risk of falls. We found Personal Emergency Evacuation Plans (PEEPs) in the fire grab bag did not include an accurate list of everyone on the premises, which meant emergency services would not know who was in the building in the event of a fire. We urgently raised our concerns with the fire service, who visited and found the provider non-compliant in multiple areas. This included a lack of staff fire safety training and fire drills, as well as locked emergency exit fire doors. The provider took action to address immediate safety concerns and put a longer-term improvement plan in place.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Since taking over the running of the care home, the provider had changed the staff team, so most staff were new to the organisation. Staff had received no supervisions since the new provider had taken ownership in May 2025. There were significant gaps in staff training, and the provider told us they relied on training completed by staff at their previous employment. This meant they had no way to ensure the training was fit for purpose and met the needs of people living at Swan Care Home. Staff did not receive practical competency checks on how to support people to move safely. There were no recruitment files held on the premises, so we could not be assured all staff had an up-to-date Disclosure and Barring Service (DBS) check, including those staff who were living on the premises. The provider confirmed to us not all staff did have a new DBS in place but carried out immediate risk assessments in this area once raised by inspectors. Training was also immediately sourced and prioritised for staff in key areas.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.The care home premises were not clean or hygienic in multiple areas, including shared bathrooms, toilets and the kitchen. There was a strong malodour throughout the day, on both occupied floors. A relative said, “[Person’s] room was lovely, but now it smells of urine.” Poor standards of hygiene placed people at the significant risk of acquiring infections. For example, we found a hot drinks machine left out for people to use containing green stagnant water in the shared conservatory, out of date food and milk in the kitchen, and dead flies and moths trapped in window screens next to food preparation areas. We also identified the provider had not registered with the local authority as a new food hygiene business as required, and so we made an urgent referral to environmental health who visited straight away. The provider was supported to register correctly and received a new food hygiene rating score of 3* (satisfactory).

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Staff did not receive any formal medicines competency assessments to check their practice was safe. Inspectors checked the number of medicines in stock against people’s records, to see whether the right amount had been given as prescribed. Whilst we found most medicines were correct, we could not check some variable dosage medicines for strong pain relief because handwritten records were illegible. This posed the potential risk of overdose. Protocols for medicines taken ‘as required’ such as laxatives and painkillers were not always in place or sufficiently detailed, and there was no consistent record of whether administering them had been effective. There were no transdermal patch application records for 1 person, or directions for staff on where to place the patches on their body to prevent skin irritation. This had not been identified and effectively acted upon through the provider’s checks and audits. However, the manager had identified this as an area requiring enhanced oversight and was in the process of supporting staff development in this area.