The Swallows

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.

The last rating for this key question was good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

We identified breaches of Regulation 12 (safe care and treatment) Regulation 15 (premises and equipment), and Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although there was a learning culture including a staff training programme in place, and managers and staff communicated well, the provider did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

We saw minutes of a meeting held with staff in December 2024 following a person who experienced an unwitnessed fall. The manager and staff discussed the person’s current health and looked at staff practices. However, we also saw that safety events involving people using the service were not always followed up and actioned as appropriate ensuring people’s safety and wellbeing.

People were supported with safe transitions and pathways. The provider made sure there was continuity of care, including when people moved between different services. A relative told us, “The staff were very good at getting the doctor involved quickly when my loved one needed to be taken to hospital.”

A visiting heath care professionals told us, “Staff are very good at seeking my help if they have any concerns. Our relationship with the service is good and communication with staff is good to make sure people are well.”

The provider had policies and procedures in place to protect people from abuse and tools were in place to monitor and oversee all safeguarding referrals. However, we found systems to manage accidents and incidents were not always effective as accidents and incidents were not always recorded and followed up on. We saw 1 person had suffered an unexplained injury. This was not documented in the person’s care plan. Staff we spoke with told us the person could bruise easily due to the medicines they are prescribed. However, this information was not documented within the person’s care plan, no body map had been completed to monitor the unexplained injury and no information was recorded relating to the incident. We checked all accident and incident records and found that the unexplained injury had not been reported and no further action had been taken to address the unexplained injury.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Information was on display within the service to support people in raising concerns and to remind staff how to report concerns. Staff told us they had received training on safeguarding adults from abuse and felt confident any concerns they raised would be managed appropriately. A staff member said, “I would report any concerns I had to the home manager. I would also report concerns to the local authority safeguarding team or the CQC if I felt I needed to.” A relative told us, “I’m happy that my loved one is being well looked after and being safely cared for.” Another relative said, “The staff understand my loved one and they are safe with them.”

The provider did not always work well with people to understand and manage risks. Risks to people were not always identified, assessed, documented, and reviewed to ensure people’s safety and well-being. Where risk assessments were completed, these were not always detailed recording how risks should be mitigated, details of the specific nature of the risk, impact on the person and the actions required by staff to mitigate these ensuring people, others, and staff were kept safe.

Three people were at risk of falls. Their falls risk assessments were completed incorrectly and their care plans failed to detail the support people required to mobilise safely. There was no guidance for staff on the safe moving and handling of people and for the safe use of equipment where required. This placed people at risk of harm.

One person’s moving and handling assessment documented the person could no longer mobilise independently and required support from a member of staff. No guidance was documented for staff on the safe transfer of the person. Their care plan documented the person was nursed and confined to bed and should be supported by 2 members of staff. This was contradictory information, and a failure to document guidance for staff on the safe transfer of the person.

A person’s pressure sore risk assessment placed them at high risk. However, there was no pressure sore care plan in place to ensure good skin integrity. One person’s nutritional risk assessment failed to document the person’s need for a modified diet and their risk of choking. Another person’s nutritional risk assessment scored the person as low risk. However, their care plan documented the person should be monitored due to their diabetes. A health care professional documented that staff should promote weight gain, however, there was no recorded information about what actions had been taken to promote the person’s weight gain. This placed people at risk of harm.

We saw notices in the kitchen advising that 1 person was on reduced portion size diet due to their GPs advice. There was no documented information in their care records relating to the GPs advice. Their care plan stated the person should maintain a healthy diet and drink plenty of fluids. Staff told us they would update the persons care plan. However, we saw the care plan had not been updated to include the GPs advice as advised.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not always detect, manage and control potential risks in the care environment. Following an incident at the service the home manager held a lesson’s learned meeting with staff. They identified that unoccupied bedrooms should be locked to keep people safe. We saw 2 unoccupied bedrooms had notices on the doors stating, ‘unoccupied room, this room is locked for health and safety purposes’, however we found these rooms had no locks. We also saw a gate leading to one of these rooms had no lock so was accessible to people residing in that part of the service. This posed a risk to people as the provider had indicated the rooms were to be kept locked for health and safety purposes. When we checked back later in the day, we saw these doors and the gate had been fitted with locks. We noted that domestic staff carried out checks on window restrictors daily.

A wardrobe in 1 person’s bedroom was leaning forward and not secured safely to the wall. This posed a risk of falling. We drew this to the registered manager’s attention who took action to address the safety hazard.

An entry/exit keypad to a front door did not work. We went through this door several times without restrictions. We raised this concern to a staff member who told us the keypad was to stop people coming to harm if they left the building. This meant there was a risk that people could leave the lounge unsupervised. We checked the keypad later that day and noted it had been fixed and was working safely.

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the time of our visit building work was being carried out to add an extension on the top floor of the building. Work had also recently been carried out on the first floor to refurbish bedrooms. These bedrooms included ensuite bathrooms with toilets. Bedrooms on the ground floor at the service did not include ensuite facilities so people used communal toilets, baths and shower rooms. We noted that some parts of the service were run down and in need of redecoration. The registered manager told us they had plans to move people to the new rooms when they were completed and to refurbish the rest of the service.

We checked fire escape routes with the registered manager. We saw signage with access to an assembly point at the front of the home. We saw gates with bolts and carabiner hooks on the stair wells. The registered manager told us these were in place to keep people that wandered with a purpose safe. A fire risk assessment had been carried out on 20 May 2025. This referred to the fire escape routes; however, it did not reference the secured gates on the stair wells that needed to be accessed by people to evacuate the building in the event of an emergency.

Following our 1st visit to the service we made a referral to the London Fire Brigade. We were advised they would be attending the service to assess fire safety procedures at the service.

One the 2nd day of our assessment we saw that the provider had removed the gates and replaced them with solid wood gates with coded keypads for entry and exit and this was linked to the fire alarm.

An officer from the London Fire Brigade contacted us following their visit to the service and told us they had assessed the evacuation procedure with staff, tested the gates and fire alarm systems and they were satisfied the home had complied with fire safety regulations.

We saw records from fire drills, monthly fire alarms system checks, fire equipment checks and evidence of staff fire safety training. We saw that people had personal emergency evacuation plans (PEEPs) in place that detailed how they would be supported out of the service in an emergency.

The provider did not always follow safe recruitment practices. We looked at recruitment records of 5 staff. We found that 3 staff application forms did not include any employment history. We asked the providers administrator if staff’s employment histories had been checked. They told us no checks were carried out on their employment histories. This meant that the provider had failed to ensure that people were supported by staff that were suitable for their roles.

This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at the training matrix, this indicated that staff had received training on moving and handling, safeguarding adults including Deprivation of Liberty Safeguards, (DOLS), fire safety, health and safety, medicines administration, Dementia Awareness, infection control, first aid, malnutrition, food handling and falls training.

Staff told us they were up to date with their training. However, we noted that staff had not received training on equality and diversity and their knowledge of the Mental Capacity Act (MCA) was limited. We brought this to the registered managers attention. One staff member told us the training they received on catheter care was helpful. Another staff member told us they had received training on diabetes. We advised the registered manager that these training topics had not been included on the training matrix. On our subsequent visit to the service, we saw an updated training matrix which included staff training completed for MCA, equality and diversity, diabetes and catheter management. Staff received supervision quarterly and had an annual appraisal of their work performance.

The provider used a dependency tool to assess the number of staff required to meet people’s care and support needs. The provider did not use agency staff. We observed there were enough staff deployed throughout the service to meet people’s needs when required.

Relatives told us they felt there was enough staff to meet their loved one’s needs. A person’s relative told us, “When we’ve visited, I can’t think of a time when there’ve been too few staff, although there have times when they’re all very busy.” Another relative commented, “They have more staff now than they used to have and my loved one feels safe with them.”

Staff told us staffing levels are good. One staff member said, “We have enough staff. We have time to sit down and talk to people.” Another staff member commented, “The manager always makes sure there is enough staff even if someone calls in sick. We can always get other staff in to cover.”

The service was not always clean. The home employed domestic staff to clean the home 7 days a week. We saw daily and weekly cleaning procedure for bedrooms. We checked 3 toilets on ground floor; not all toilets had a soap dispenser, paper towels and bins. We drew these concerns to the registered manager’s attention. They told us they would get electric hand dryers installed in the toilets. However, on our return to the service we saw soap, bins and paper towels in all the toilets on the ground floor.

We spoke with domestic staff and the homes administrator. They told us there was no cleaning procedure in place for domestic staff for the communal toilets. They told us they would develop a cleaning procedure for communal toilets.

This is a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A person’s relative told us, “The home always looks clean and tidy. The only improvement that occurs to me is that they need to upgrade the downstairs toilet facilities.”

We noted some malodours around the service in morning on our first site visit. This was before people had received personal care from staff. There were no malodours in these areas when we checked again in the afternoon.

Following our first site visit the area manager sent us an infection prevention and control self-audit tool kit. This included, for example, the need to replace some pedal operated bins and introducing a new cleaning schedule that covered all areas of the service including toilets. They also sent us a bathroom and toilet cleaning schedule. This included checks for soap, paper towels and waste bin.

Staff were provided with personal protective equipment (PPE) when required. Training records confirmed that all staff had received training on infection control.

Monthly infection control audits were also carried out in the kitchen. The service had received a 5-Star food hygiene rating from the food standards agency in December 2024.

Medicines were not always managed safely. Care plans and medicines records failed to contain detailed information about people’s specific health conditions or how these should be managed. Protocols for ‘as required’ (PRN) medicines were not in place to guide staff on when to administer these medicines.

Staff told us that 6 people received PRN medicines. However, we noted that a seventh person’s care plan stated they received PRN medicines. Staff told us that the information within the care plan was incorrect and required updating.

We asked to see the PRN protocols for the 6 people receiving PRN medicines. Staff told us that there were no PRN protocols in place. This placed people at risk of medicines mismanagement. Following our assessment of the service, the provider sent 6 completed PRN protocols for people who received PRN medicines. However, these were not fully completed and comprehensive providing staff with detailed guidance on when and how to administer PRN medicines.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines were administered by trained staff who had completed up-to-date medicines competency assessments. Staff were observed checking MAR (Medicines Administration Record) charts carefully before administering medicines.

A person’s relative told us, “My loved one gets their medications regularly; they take a lot and there hasn’t been a problem.”