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.At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant services were not planned or delivered in ways that met people’s needs.

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

This service scored 36 (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 and risk assessments were generic and not fully personalised to people’s needs. For example, 1 person had a risk assessment in place to guide staff on how to support them if the person became very distressed. The document included information such as, ‘I thrive when someone takes time just for me’, ‘Joining in helps me feel uplifted’ and ‘Celebrate the small wins with me – they mean more than you might think.’ This did not give any specific information to staff about how the person liked to be supported. At the last inspection we found daily care notes were task orientated and did not consider people’s wellbeing or quality of life. Although the provider told us they would address this concern, no improvements had been made in this area.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity. We received some mixed feedback from relatives about the continuity of care at Swan Care Home, due to changes in the staff team. A relative said, “They had brand new staff here and they are so kind and thoughtful.” However, another relative said, “The old staff knew [person] well, with the new ones, the staff turnover is high. [Person] is used to seeing familiar faces and new faces are confusing. I hope this will settle down.” We did receive some positive feedback about staff working with other professionals. One professional said, “The care workers were all willing to work with me to achieve a positive outcome for [person].” However, due to the extent and seriousness of the provider’s failings, all people were supported to move out of the service during the inspection, uprooting their sense of comfort, home and security. This reflected a serious lack of care continuity, as people had to leave their home due to the poor safety and quality of the service under the provider’s ownership.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. An Accessible Information Policy was in place, setting out a commitment to providing information in a way which met people’s individual communication requirements. Records showed people’s communication needs were set out in care plans, in some cases with clear and detailed information, showing some improvements in this specific area. For example, 1 person’s care plan stated, ‘Approach [person] calmly at eye level and use a gentle manner’ and ‘Allow plenty of time for [person] to process information and respond.’ However, whilst communication techniques were clearly set out, they were not always applied in practice. This was demonstrated in Mental Capacity Assessments (MCAs), where no reference was made to how staff had met people’s recorded communication needs and preferences to support decision making. We also saw some information on display for people had a font size which was too small to easily read, including for those who may have a visual impairment.

The provider did not always 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. Records of complaints and compliments were held on file, showing the service had received some positive feedback about staff care and support. Satisfaction surveys were also sent out to relatives to gain their views. However, some relatives told us communication with the service was not always clear. A relative said, “I have been happy, but I am beginning to have doubts now. Since the new managers, it seems that no-one is telling each other what is going on.” Another relative said, “I would say that there is a lack of communication from the home, [and] it is difficult to get there.” However, another person’s relative said, “[Swan Care Home] is easy to get hold of and responsive to what I say. The new manager is going to hold meetings for family members.”

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it. Since the last inspection, there had been some improvements to the environment to make it more accessible, such as installation of some dementia-friendly signage. There had also been work carried out to the conservatory and to the garden to make it more inviting. A staff member said, “From what I see, the [care team] work very hard to make sure the residents always have what they want and need, whether it is food, drink, a certain song or television show, time outside or just a bit of company.” Despite this, there were still clear hazards in the environment, which meant the care home was not always safe and accessible for people living with a physical disability, or with dementia. This meant the provider had not demonstrated how they made reasonable adjustments for people, including addressing communication barriers and ensuring safe and accessible premises.

The provider did not actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. This included people living with dementia or other healthcare conditions, which meant they were less able to advocate for themselves without support. The provider failed to understand people’s care and support needs, which meant barriers were not proactively identified and addressed in response leading to poor equity in experiences and outcomes overall. This included in relation to people’s human rights and protected characteristics.

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. At the last inspection we found people did not have care plans which set out personalised comfort measures to support their wellbeing. At this inspection, people still did not have holistic end-of-life care plans to show how they would like to be looked after when very unwell. We found some records only contained basic information about Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR). For example, 1 person’s end-of-life care plan stated, ‘I have a DNACPR in place within my care records. I currently have no additional care needs identified in relation to death and dying.’ This was despite a substantiated safeguarding concern which found staff failings relating to a lack of welfare checks and pain relief, which impacted on a person’s comfort and dignity. An outcome from this safeguarding investigation was for the provider to improve care planning to promote compassion and dignity, but the provider had failed to complete this. Additionally, not all staff had training in this area. This placed people at significant risk they would not be cared for with dignity at the end of their life.