Swan Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. 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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Despite the multiple shortfalls identified during our inspection, there was no overarching service improvement plan in place to set out the priorities and vision for the service, and to guide the manager on areas for immediate attention. There were no shared values co-produced, discussed or agreed with staff, to develop engagement and ownership. The provider was failing to meet their own aims and ambitions as set out in the company statement of purpose. This document stated, ‘By combining professional expertise with genuine compassion, we create an environment where elderly individuals, including those living with dementia, can feel valued, respected, and supported. Our goal is to ensure that every resident, regardless of their circumstances, lives with dignity, purpose, and the highest quality of care.’ This was not being achieved in practice and reflected a failure to meet the commitments made by the provider to people in their care.

The provider did not always have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. There was a lack of effective leadership, with no registered manager in post. Due to circumstances beyond their control, the Nominated Individual had to take time away from overseeing the service. However, there were no robust contingency measures in place. A new manager had started in post but had not yet had time to complete the improvement works required. There was also no deputy manager, and we saw the manager covering their own role as well as that of other staff members who needed support, which left them overstretched. During the inspection, we raised our urgent concerns with the provider about governance of the service, who provided assurances and immediately arranged extensive consultancy support. The consultancy team put a new service improvement plan in place and has committed to sending this to the CQC regularly for review, to demonstrate ongoing improvement works.

People did not always feel they could speak up and that their voice would be heard. There were multiple warning signs of a closed culture forming, with evidence of weak leadership, normalised restrictive practice, and institutionalised care, as well as staff reliant on the provider for both employment and accommodation. Despite this, staff told us they felt the change in management had been positive, and they would be able to raise any queries or concerns. A staff member told us, “The manager is very supportive, [manager] would help us, any concerns we let [them] know.” The manager needed more time in post, with provider support, to ensure a positive and open staff culture was established, embedded and sustained.

The provider did not demonstrate value in diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There were also no staff recruitment records which were accessible and no supervisions were in place to set out measures put in place by the provider to promote equality, show decision making, or to meet staff needs relating to protected characteristics. The majority of staff who had joined the service were from overseas, and there were concerns about inclusion and support. For example, 1 staff member told us they had experienced racist behaviour. The new manager had taken action to try to address racial abuse of staff, but significant work was still needed to ensure support for the workforce, including in relation to safe working patterns.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The new manager had started to introduce new audits and checks, but these systems were in their infancy and required development and embedding. Oversight processes already in place were ineffective. Legal and regulatory requirements, such as submitting statutory notifications to the CQC, were not met. Recent changes to both management and staffing had caused instability at the service, with some previous care staff leaving or being replaced by the new provider. This had not been managed well. A relative told us, “The previous care workers were part of the community, and they were fond of [person]. [Person] is not engaged anymore.” However, another relative said, “The new staff are more noticeably doing their jobs.” We received a significant number of concerns and complaints following the change in ownership. A staff member told us they felt complainants had, “Been trying to cause trouble for the new owner...” Another staff member expressed anxiety about the financial sustainability of the business. A relative told us, “I knew the previous management, and this one is no worse.”

The provider did not collaborate and work in partnership with others, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. We had to raise multiple safeguarding alerts with the local authority and seek support for the service from external stakeholders through referrals to fire service and to environmental health. We received positive feedback the service worked with system partners to address gaps in the safety and quality of the service, although this largely followed urgent referrals made by the CQC to support the service in the immediate term. However, it was also recognised by stakeholders the service had been through change and instability and were in the early stages of working towards improvement. A professional who works with the service told us, “As you know, the ownership of the care home changed over the recent months and since then, there have been a number of changes in staff. I think this did pose some challenges, but the new team is working collaboratively with the wider team to provide appropriate level of patient care.” More time was needed to see how this work was embedded to support improvement and quality of care in the service.

The provider did not have a system in progress to focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Due to the significant failings identified at this inspection, consultants acting on behalf of the provider were still reactively responding to concerns raised by external stakeholders and were not yet able to focus on proactive development of the service, or any innovative practice.Prior to this, the manager was working with chaotic and disorganised legacy systems, without any clear metrics for evaluating the success of changes and improvements made. However, the provider confirmed their ongoing commitment to working with other professionals to drive rapid improvement across the service, and to reflecting on lessons learned in relation to the outcome of this assessment.