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.At our last assessment we rated this key question inadequate. At this assessment the rating has remained 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 continued breach of legal regulation in relation to governance at the service.

This service scored 25 (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. There was no shared vision or direction for the service, and no clear strategy or priorities determined by the provider to guide the new manager in their role. Although a service improvement plan had been developed, it did not clearly set out which areas required the most urgent attention. Some actions had also been marked as ‘completed’, despite inspectors finding continued concerns. In addition, where other actions had lapsed past the planned due date for completion, there was no recorded risk mitigation. The service was still not meeting its own aims and objectives as set out in the Statement of Purpose, including a ‘Commitment to delivering exceptional care.’ Staff and relatives were initially not kept up to date about people moving out of Swan Care Home or the future of the service, with concerns expressed to CQC showing poor communication and openness from the provider about this process.

The provider did not 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 have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. The leadership of the Nominated Individual was poor and did not reflect a realistic understanding of how to safely run a care home or the role of other stakeholders and regulatory bodies. This included requesting the CQC return to reinspect the service, stating there had been sufficient improvements, which did not reflect the evidence we found. There had been no registered manager in post since August 2025, despite this being a condition of registration with the CQC. The provider had sought consultancy support after the last inspection in November 2025 but had failed in this short timeframe to work effectively with 2 managers, consultancy firms, or with external stakeholders such as the local authority. Another new manager had just started in post on the first day of our inspection. The new manager had been placed ‘on call’ all week by the Nominated Individual, despite not having completed their induction and whilst unfamiliar with staff, people and systems. There had also been limited operational handover from the previous manager. A relative told us, “The handover to new managers wasn’t good.” Staff were positive about the new manager; however, the new manager did not have any history of turning around Inadequate rated services. A staff member said, “We just need a permanent manager. We are confident in [new manager].” There was also no deputy manager to support with all the improvements needed, leaving the new manager without capacity to complete this significant workload.

People did not feel they could speak up and that their voice would be heard. Whilst staff told us they could speak with management, significant continued closed culture indicators at the service made this challenging in practice. A staff member said, “[New manager] has listened to me and helped when I've been to the office for help or advice, and we are having team meetings much more regularly which I've found useful.” However, some staff continued to be reliant on the provider for both employment and accommodation, creating a significant power imbalance which meant they might not be able to speak freely. This was a known issue which had not been addressed. There was a concerning lack of transparency at provider level, with missing or false documentation, and contradictory information provided to inspectors about the use of the on-site staff flat, staffing levels at night and people’s valuables stored in the care home safe. We also found CCTV in all shared areas included the main office, reducing the effectiveness of any ‘open door’ policy if staff wanted to speak with the manager privately. This posed a significant closed culture risk.

The provider did not value 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. Inspectors found continued concerns where staff were subjected to unfair and excessive working hours and received a lack of formal support from the provider. Although some staff described effective team working amongst themselves, the provider failed to arrange staff training to support equality and diversity in the workplace, with a compliance percentage of just 31%. Due to significant concerns about the unethical treatment of staff by the provider we raised this as a concern with the local authority safeguarding team.

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 provider’s own oversight and governance systems, including audits and service improvement plans had either failed to identify shortfalls, or action had not been taken to address concerns fully in a timely way. Audits were disconnected, and there was a lack of continuity due to auditing being completed by different managers, senior care workers or consultants. For example, we saw unrestricted windows had been identified as a concern in an environmental audit 2 months prior to our inspection, but no action had been taken in response. Care planning and dignity audits had failed to find shortfalls as set out in this report. Policies were not always fully completed or tailored to the service. The provider was failing to meet their legal and regulatory obligations in multiple areas, including a failure to have a registered manager in post, or to inform the CQC by way of statutory notification of instances of abuse at the service. During the inspection, we had to formally write to the provider setting out our urgent concerns relating to fire safety, which had not otherwise been identified and addressed, despite being raised at our last inspection in November 2025.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The provider did not demonstrate effective team working with system partners, including poor communication about changes at the service and non-adherence to assurances provided to the local authority and to the CQC. There had been a lack of significant progress despite the input of multiple external agencies, including the local authority quality and safeguarding teams, the fire service, and multiple managers and consultants. This location was rated Good under the previous provider. Since taking over ownership in May 2025, the new provider had received 2 Inadequate CQC ratings, breached multiple regulations, been issued with an enforcement Warning Notice, and had its local authority contract revoked all in a short space of time, showing immediate and significant failings. This has led to the loss of a valued amenity in terms of Swan Care Home as an established service supporting the small local community.

The provider did not 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. A learning culture was not demonstrated at this location, with many of the same concerns outstanding from our inspection of November 2025. Despite providing assurances rapid improvement work would take place after our last inspection, this had not been completed. The service could not demonstrate innovative practice and had not made improvements even when focusing on a reactive response to external concerns with significant support. Additionally, the provider failed to take ownership or accountability for the myriad failings identified, and no lessons had been learned as a result.