The Swallows

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Good

• Responsive

  Good

• Well-led

  Inadequate

Our view of the service

Date of assessment: 29 May, 4 and 12 June 2025.

The Swallows is a care home without nursing for up to 33 older people, some of whom are living with dementia. At the time of our assessment there were 27 people living at the service.

The last rating for this service was ‘Good’ (published 3 September 2019). At this assessment we identified breaches of Regulations relating to need for consent, safe care and treatment, premises and equipment, staffing and good governance. We have told the provider to make improvements. We have asked the provider to complete an action plan to tell us about the improvements they are making.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.

At the time of this assessment the registered provider was also the registered manager for the service. However, they employed a home manager to run the service. The home manager was not available during the on-site assessments.

We spoke with the registered manager and the provider’s operations manager. We also spoke with 8 staff, including care staff, kitchen staff, domestic staff, activities coordinators and the maintenance person. We spoke with 2 visiting health care professionals.

Risks to people were not always identified, assessed, documented, and reviewed to ensure people’s safety and well-being. Mental capacity assessments were not always completed in line with the codes of practice. People’s medicines were not always managed safely. Premises and equipment were not always kept clean and safety checks were not completed in line with legislation and guidance. The provider did not always follow safe recruitment practices. There were no robust, clear and effective governance, management and accountability arrangements in place to oversee the service delivery and ensure people’s safety.

This service is being placed 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 time frame within which providers must improve the quality of the care they provide.

People's experience of this service

During the assessment we spoke with 4 people who used the service and 1 visiting relative. An Expert by Experience (ExE) spoke with 11 relatives by telephone to seek their feedback on the care received by their loved ones. People spoke largely positively about the care and support their loved ones received. People told us staff were kind, caring and empathetic, staff communications with relatives was good, and the accessibility and responsiveness of management and staff was good.

While the people we spoke to expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards.