Swanholme Court

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 as good. At this assessment, the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always demonstrate a consistent learning culture. Systems were not always effective in ensuring learning was identified, recorded and used to improve practice. Records did not always include enough detail to fully review incidents or identify patterns, which meant opportunities to learn and reduce future risk were sometimes missed.

This was particularly evident in incidents involving people becoming distressed. In these cases, staff did not consistently explore the underlying causes or use this information to update care or inform future support. As a result, learning was not always embedded into practice, and the provider did not always take a proactive approach to managing risks and preventing similar incidents from occurring again.

Systems were in place to report and review accidents and incidents, including falls and medicines errors. Accidents such as falls were generally managed appropriately, with action taken to respond to immediate risks and keep people safe. Records showed that incidents such as falls were reviewed and analysed to identify patterns and trends, and this information was used to inform preventative measures and reduce the risk of recurrence.

Systems to support communication were in place; however, these were not always consistently applied. Staff told us they did not always receive important updates about people’s care, such as changes in health, treatment or significant events, as information was not always shared clearly between teams. While this did not routinely impact people’s care, it meant there were occasions where information sharing could be improved to support greater consistency.

The provider had taken steps to strengthen communication by changing the staffing structure, so staff worked within one home rather than across services. This had improved continuity and supported better information sharing within teams. There was a coordinated approach to maintaining safe systems of care, including when people moved between services.

Staff described processes for sharing information when people moved into the service, including assessments, visits and developing care plans to guide staff. Information was also shared with relevant professionals such as GPs and hospitals, which supported continuity of care.

Relatives told us that people’s moves between services were generally well managed. One relative described the process as “Very smooth”, while another said, “[My family member came] from the hospital. They supported us and shared information.” This reflected that transitions into the service were organised and supported by effective information sharing.

Systems were in place to safeguard people from abuse and harm. Staff described how they would recognise and report concerns and knew who to escalate these to, including within the management team and to external agencies where needed. There were processes in place to record concerns and share information with relevant professionals, which supported people to remain safe.

Relatives gave positive feedback about people’s safety. One relative said, “They are absolutely brilliant. [My family member] said, I am safe here,” while another told us, “I would speak to the manager. Never needed to.” This showed people felt safe and understood how to raise concerns if needed.

Staff told us they felt able to raise safeguarding concerns and understood their responsibility to do so. Training was provided to support staff in recognising signs of abuse and responding appropriately.

Records showed that concerns were reported and shared with the local authority when required and the provider made applications for Deprivation of Liberty Safeguards (DoLS) when appropriate.

However, staff knowledge of wider safeguarding frameworks was variable. Some staff had a limited understanding of the Mental Capacity Act 2005 (MCA) and DoLS, and how these related to their own roles. Despite this, we observed staff working in line with these principles in practice, supporting people in a way that respected their rights and involved them in decisions about their care.

Following feedback, the provider recognised the need to strengthen staff understanding and had plans to include discussions on key topics such as the MCA and DoLS within staff supervision, to improve staff knowledge.

Risk management was not always fully effective or consistently applied. Care plans did not always contain clear or detailed guidance to support staff to manage known risks. For example, where people experienced distress or changes in behaviour, records did not always clearly describe potential triggers or provide consistent strategies for staff to follow. There was limited evidence that staff considered or sought to understand why people became distressed. This increased the risk of inconsistent responses and repeated incidents.

Information from incidents or changes in people’s needs was not consistently used to review and strengthen risk assessments. In some cases, tools to support the recognition of risks, such as pain, were referenced but not clearly embedded into practice, which increased the risk that people’s needs were not consistently identified or managed.

People were supported to stay safe through systems that assessed and managed risks. Risk assessments were completed and contained guidance for staff on how to support people and reduce the risk of harm. Staff described how they would escalate concerns and seek support from healthcare professionals when risks changed, for example where people developed swallowing difficulties or showed signs of deterioration.

The environment supported people to remain safe and was appropriately maintained. Premises were suitable for the needs of people using the service and equipment was available to support safe care delivery. Staff described how they would report any environmental concerns and action was taken to address maintenance issues when identified.

Relatives told us the environment supported people to remain safe. They described the home as safe and secure, with effective access arrangements in place. They told us appropriate equipment was available to support people’s needs, such as hoists and mobility aids, and that staff supported people to move around safely.

Basic checks and processes were in place to support the safety of the environment. Staff were aware of their responsibilities in reporting faults or hazards and described how concerns were escalated to senior staff. There were arrangements in place to ensure equipment was available and used appropriately to support people safely. This meant risks within the environment were generally identified and addressed in a timely way, supporting people to remain safe.

Fire safety arrangements were in place, including an evacuation strategy supported by staff training, evacuation equipment and personal emergency evacuation plans (PEEP). Regular fire drills, including night scenarios, were carried out. While these arrangements were considered suitable by the provider, improvements were being made to further strengthen assurance, including more detailed recording of evacuation exercises and planned simulation of worst‑case scenarios to test staffing levels and response.

Some staff described inconsistencies in leadership and support, particularly during a period of change. A new manager had started at the time of inspection, which was expected to provide greater stability and further strengthen oversight moving forward.

Relatives’ feedback about staffing was mixed. While some felt there were enough staff to meet people’s needs, others described periods where staffing felt stretched, particularly at certain times. However, these experiences were not consistent. Overall feedback reflected that staff knew people well and were able to provide appropriate care. Rotas demonstrated that staffing levels were planned in line with assessed dependency levels, and people were supported safely.

Staffing arrangements supported safe and effective care, with trained staff available to meet people’s needs. Staff told us there had been some periods of short staffing, often due to sickness, which could make the role more challenging. However, most staff told us staffing had improved and described the service as generally well-staffed.

Staff received training to support them in their role, including face-to-face and online learning, and described this as good. New staff completed an induction and there were ongoing opportunities to develop skills. Staff told us they felt supported by senior staff on shift and could seek guidance when needed, which supported the delivery of care.

Recruitment processes were mostly followed. However, some staff files contained minor gaps in employment history that had not been fully explored. The provider had identified this and there were processes in place to strengthen oversight and ensure all required checks were completed consistently.

People were protected from the risk of infection through effective infection prevention and control measures. The environment was clean and hygienic, and staff had access to appropriate personal protective equipment (PPE). Staff understood when to use PPE and how to maintain cleanliness within the service.

Relatives told us the home was clean and well maintained. They described seeing staff and cleaners regularly carrying out cleaning tasks, which reassured them that hygiene standards were being maintained.

Cleaning routines were carried out, and we observed good standards of cleanliness across the service, including communal areas such as the kitchen and laundry. This meant people were supported in an environment that reduced the risk of infection.

There were some inconsistencies in how cleaning records were completed. On occasions these had not been fully completed, and records did not always reflect practice as some tasks were duplicated or no longer required. This meant records did not always provide clear assurance of what cleaning had been carried out.

These issues did not appear to impact the overall cleanliness of the environment but indicated that recording processes required review to ensure they accurately reflected practice and provided clear oversight of infection prevention and control.

The staff did not always follow the provider’s policy, which required any handwritten medicines records to be checked and signed by a second trained member of staff to confirm they had been transcribed correctly. In one example, dosing instructions recorded did not match the pharmacy label and this had not been identified through audits or by staff over a long period of time. Whilst the medicine had only been administered once, which reduced the immediate risk, this highlighted a gap in oversight.

There was insufficient guidance in care plans to support staff on when to administer medicines given as required (PRN), particularly for people who were distressed. PRN medicines for distress were not commonly used, and we saw only one occasion of administration. However, there was limited oversight of PRN use, which increased the risk of medicines not being administered as intended and decisions not being made consistently or with clear justification.

Other aspects of medicines management were carried out safely. Creams and lotions were recorded appropriately with body maps to guide application, and robust processes were in place for medicines administered via patches. Where medicines were given covertly, appropriate assessments and documentation were in place to support safe practice. Audits were completed to monitor medicines management, although these had not identified the issues found during the inspection.

People were mostly supported to receive their medicines safely through established systems for storage, administration and recording. Records we reviewed showed people mostly received their medicines as prescribed and at the required times, and no missed doses were identified. Stock balances were accurate, and appropriate arrangements were in place for the management of controlled drugs and temperature monitoring. Staff received training and had their competence assessed to support safe medicines management.

Relatives generally felt medicines were managed safely. They told us staff supported people with their medicines and communicated with them about changes, involving healthcare professionals where needed to ensure appropriate treatment was provided.