Swan Care Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Inadequate

• Responsive

  Inadequate

• Well-led

  Inadequate

Our view of the service

Date of Assessment: 18 May 2026 to 9 June 2026. The service is a residential care home providing support to up to 21 people, including those living with dementia. At the time of our inspection, there were 10 people living at Swan Care Home, as the local authority had placed an embargo on any new admissions due to quality and safety concerns.

We carried out this inspection to follow up on enforcement action. At the last inspection we found 9 breaches of regulations, the service was rated Inadequate and placed into special measures. At this inspection we found 8 continued breaches relating to person-centred care, dignity and respect, consent, risk management, safeguarding, premises, governance, and staffing. Improvements had been made to recruitment practice, and the service was no longer in breach in this area. ​

Governance and oversight measures were extremely poor, and the provider had failed to rectify widespread and significant concerns identified by the CQC. The provider had failed to work with multiple managers or consultants since taking over the service in May 2025. A fourth new manager had just started at the time of our inspection. People did not receive person-centred, dignified care, and were placed at the potential risk of avoidable harm. We made multiple referrals to help keep people safe during the inspection, including to the local authority safeguarding team and to the fire service.

In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

Whilst some people expressed general satisfaction with their care, our assessment found care did not meet the expected standards. We received some positive feedback about care staff working at Swan Care Home and heard how they had sought to care for people within the best of their abilities despite significant provider failings. A relative said, “From my point of view, it is clean and always looks okay, no problems. I think they are doing a good job; staff are upfront and good.” The relative also told us, “[Person] smiles when [staff] talk to [them] and [staff] talk to [person] and ask what [person] wants for dinner. I am happy with the way they do that.” Another relative said, “There could be more staff there, [person] is funded by the council. [Person] is clean and washed, but you don’t see lots of staff around.” We received feedback the new manager was approachable, but there were also concerns shared about the constant changes at the service which led to instability and a lack of consistency. A relative said, “I think they are pretty good to be fair. New managers are helpful.” However, another person’s relative told us, “I am not sure [Swan Care Home] know the residents.” Whilst relatives told us they felt able to raise any issues or concerns, we were informed there was sometimes a lack of consistent communication. A relative told us, “I would speak to the staff and the manager. I don’t know the new team and so I don’t know how they would respond.”