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. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal regulation in relation to risk management including medicines, environment, staffing, and safeguarding. Improvements had been made to recruitment practice, and the service was no longer in breach of regulation in this area.

This service scored 28 (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 honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. At the last inspection we found there was no meaningful overview or analysis of accidents, incidents, falls or safeguarding to reduce the risk of reoccurrence. This was a continued failing which had not been addressed, placing people at the risk of avoidable harm. For example, we saw 1 person regularly became distressed and posed a risk to themselves or others, but no action had been taken to assess incidents, to identify triggers and improve the safety of their care and support. This had led to the person, other people living at Swan Care Home, and care staff sustaining injuries. We raised our concerns with the local authority safeguarding team as a result.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. At the last inspection, people did not have accurate care plans and risk assessments to ensure they would be supported safely if moving to other services, such as an admission to hospital. This was a continued concern which had still not been addressed. Due to widespread safety and quality concerns, the local authority cancelled its contract with the service during our inspection and began to support people to move out of Swan Care Home. We received feedback the provider did not always work well with stakeholders to support this process. The provider told us they were seeking to admit people who pay for their own care instead, at a rate of 1 new person a week. We asked the provider to self-embargo the service whilst safety issues were addressed, but the provider declined to do so for more than a period of 2 weeks, stating this timeframe would be sufficient to embed changes. This did not demonstrate a realistic approach to understanding the risks at this location or scale and breadth of non-compliance.

The provider did not work 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 and failed to protect people’s safety and rights. Due to a failure to identify safeguarding concerns from incidents, the provider had not made statutory notifications to the CQC as required. The safeguarding policy was a template and had not been tailored to the service or local area, so staff did not have information about how to escalate concerns externally. People’s money was not managed safely by the service, and we found multiple items of jewellery and cash in a safe. Leaders did not know who the items belonged to, including sentimental items such as rings and necklaces. There were no financial records about how people’s money had been spent, including where people did not have capacity to manage their own finances. A relative said, “I asked [Swan Care Home] to invoice me, and it is a bit confusing, they don’t follow up. We have no record of what [person’s] money has been spent on, we have asked for an itemised bill.” The CQC made multiple safeguarding referrals across the course of this inspection to help keep people safe, including in relation to fire safety, risk assessments, lack of legal frameworks for capacity and consent, unethical staff treatment, and a lack of any financial recordkeeping.

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. We received feedback people felt safe with staff during day-to-day interactions. One relative said, “The general feeling is that they are keeping [person] safe.” However, the provider had failed to ensure staff had all the information they needed to carry out their roles. Whilst some risk assessments were in place, they were not always accurate, up-to-date, or fully triangulated with other care records. This was a continued concern and placed people at the potential risk of avoidable harm. We found a care plan for 1 person continued to contain contradictory information about their mobility which could lead staff to provide unsafe support. There were also errors and inaccuracies relating to key safety areas for multiple people, including choking risks, modified diets, skin integrity, fire safety, and ensuring adequate hydration. During the inspection, social workers completed assessments for everyone living at Swan Care Home to support them to move out safely.

The provider did not always 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. We found the environment was still not safe and suitable for use. The provider had made limited improvements to fire safety. A relative said, “[Swan Care Home] changed some fire doors after the last inspection and there is a fire exit.” However, we identified continued concerns and made an urgent referral to the fire service, who found the service was still non-compliant overall. The provider had adopted a ‘stay put’ evacuation policy in the event of a fire where people did not immediately leave the building, seeking to reduce the number of staff members working at night. There was no clear rationale for this policy; it had not been tailored to the needs of people living at the service, and there was a lack of fire drills. Additionally, staff who were designated Fire Marshalls could not explain the evacuation policy when asked. Personal Emergency Evacuation Plans (PEEPs) were inaccurate and did not record key information such as a person’s correct location in the building, and the use of any flammable emollient creams which could place them at increased risk in a fire. We also identified new and continuing environmental hazards. Multiple windows on the first floor were unrestricted, placing people at potential risk of falling from height. Inspectors also found 2 sluice rooms unlocked, as well as pest control poisons in the upstairs hallway, leaving dangerous chemicals accessible to people living with dementia. Leaders acted, at our request, to address inaccurate PEEPs, and to secure unsafe windows, but had not acted on this independently to reduce risk.

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. A relative told us the service, “Could do with more staff.” Another person’s relative said, “I get the impression there is a high use of agency staff at the moment.” However, we also received comments from a relative who said, “There are plenty of staff bobbing about.” Despite this mixed feedback, we found continued concerns that staffing was unsafe, particularly at night. Following a recent safeguarding concern, where multiple instances of neglect were found overnight due to short staffing, the provider had given assurances to the Care Quality Commission (CQC) and the local authority there would always be 3 staff on the night shift. However, we completed an unannounced night visit and found rotas completed by the provider stated there was a third staff member on shift but was not in practice, showing a lack of openness and transparency. The provider was instead relying on unsafe and unethical ‘on call’ arrangements, using the support of staff living in an on-site staff flat. This meant staff were officially on the rota in the day and then ‘informally’ on call throughout the night, working excessive hours without breaks. The Nominated Individual told us after the last inspection that this staff flat would be decommissioned but had not completed this, until concerns were again raised by CQC. We also found new staff did not have all necessary training, and training compliance levels overall were poor. The provider was also relying on training staff had received in previous care roles, which was a continued concern. Inductions were missing or poorly completed. There had been improvements to recruitment practices overall, although minor issues remained such as ensuring references were sought from all previous care positions. We raised this with the provider to follow up.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We found there had been improvements to the cleanliness of the service, and the domestic team worked hard to ensure standards were met. A relative said, “[Swan Care Home] always looks good, and we see the cleaners going around.” Another person’s relative said, “It is clean and well-presented.” However, as the provider had failed to fully resolve some maintenance issues, this meant parts of the building were tired and some areas could not be fully cleaned. A relative said, “It is okay, it is a bit old, some [bedrooms] have no bathrooms.” Additionally, not all staff had food safety hygiene training, and we saw the provider had assigned untrained staff members to carry out food preparation. Good food hygiene practice was not always adhered to, for example, we found an unclean used fly swatter stored on top of the personal protective equipment (PPE) dispenser for kitchen staff use. This placed people at the risk of unsafe food practices, which could lead to food poisoning or sickness.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not involve people in planning. A sample of medicines were checked by inspectors, and we found the correct amount in stock according to records, indicating the correct number of medicines had been given as prescribed. A relative said, “A staff member does the medications and we have no worries.” There was a new manager on site, who was carrying out audits using their experience as a registered nurse. However, there were continued concerns about ‘use as required’ (PRN) medicine protocols for people, such as laxatives, lacking in detail as to when they should be given. Medicines allergies were not clearly and consistently recorded, with missing information found in documentation such as medication administration record sheets (MARs). We also identified shortfalls in relation to people’s capacity and consent. For example, 1 person had been assessed to have capacity to make decisions about their own medicines, which would include the right to refuse them. However, medicines were being given to the person concealed or disguised without their knowledge or agreement, a serious breach of the person’s rights.