The Swallows

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.

The last rating for this key question was good. At this assessment the rating has changed to 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.

We identified breaches of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 Care Quality Commission (Registration) Regulations 2009

This service scored 36 (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, equality and human rights, safety and diversity and inclusion. They provider did not always understand the challenges and the needs and risks of people they supported.

The culture of the service did not always support the delivery of good safe quality care. A robust system for the monitoring of quality and safety within the service was absent. Learning, improvement and monitoring was not routinely undertaken and action plans that were implemented were not monitored to ensure actions had been taken to address shortfalls. This meant opportunities to help drive service improvements were missed. For example, around the management of risk and safeguarding people and the safety of the premises.

The provider did not have inclusive leaders at all levels who understood the context in which they were required to deliver safe care, treatment and support to people using the service. The provider had obtained legal authorisations for restrictions of people’s liberties. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguarding (DoLS). However, the registered manager had failed to complete CQC statutory notifications for DoLS authorisations as required.

This is a breach of Regulation 18 Care Quality Commission (Registration) Regulations 2009

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 our site visits. The provider had also recently appointed an area manager the oversee their care services. On the second day of the inspection the area manager told us they had been employed for 2 weeks, and they were in the process of assessing and helping to make improvements at the service.

Staff spoke highly of the home manager. One staff member told us, “We are well supported by the home manager, we can talk to them if we have any concerns about the residents, there are regular staff meetings and supervisions.” Another staff member said, “The home manager is always concerned about staff and makes sure we are all okay.”

Management support was available for staff when they needed it. There was a 24 hour on-call number where staff could contact managers if they need any advice or support.

Relatives spoke highly of the home manager and administrator. One relative said, “The home manager is approachable and hands on; if you’ve got a problem, she’s easy to talk to and importantly she acts on it.”

The culture of the service did not always actively support freedom to speak up and to take action to drive service improvements.

There were systems to enable people and their relatives to speak up. Minutes from a residents meeting showed people had highlighted the need for improvement with food, the cleanliness of their rooms and the activities on offer. People said it would be nice to get out into the garden once building work was finished and it would be nice to have more singers attend the service. An action plan from the meeting had facilitated 2 people going on a bus trip and arranging a trip to the seaside. People told us that the food had improved.

One relative said, “The service is good at communicating with us; letting us know what’s going on. If I had any concern I would email the administrator as the first point of contact, but I haven’t had any issues.” Another relative commented, “The home manager is always there to listen, and the administrator is also very good; I can talk to them any time about my loved one.”

The provider supported staff to feel included and treated them with equity, taking account of their individual needs. However, the provider did not always provide the right training and ensure it was embedded into practice to deliver person centred care or care that promoted the rights of individuals particularly people living with dementia.

There were no robust, clear and effective governance arrangements in place to oversee the service delivery and ensure people’s safety. Records were not always contemporaneous, and assessments and tools were either not in place and or not completed appropriately or at all. Information and processes were lacking and not used effectively to monitor and improve the quality of care.

We noted there were lots of separate audits and checks in place, however, there was no principal quality monitoring/assurance tools in place that drew all these together. The audits and checks included monthly medicines, infection control and care plan audits, a service improvement plan dated 8 June 2025, minutes of a health and safety meeting dated January 2025, provider visit report from March 2025 and an annual development plan for 2025. We saw an unannounced visit report carried out by the home manager in March 2025 and a mealtime audit report from May 2025. These had identified areas for improvement however, there was no indication in any of these stating a date for completion and by who.

The service improvement plan had been updated (during our assessment) on 8 June 2025. This recorded some actions that had been previously completed in March 2025 and new actions to be completed, including for example, introducing pictorial menus, replacing bed bumpers, purchasing spillage kits for the laundry and introducing new housekeeping documents to be put in place by June 2025. This did not include any of the issues we found in relation to care plans and risk assessments, people’s capacity to make decisions, recruitment records, medicines management, infection control and the environment.

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also saw records confirming regular checks were carried out on gas safety, portable appliances, legionella, lifting equipment such as slings and body hoists and food safety. Audits were also carried out on the kitchen, hand washing, safeguarding and activities.

The area manager told us their aim was to review and improve the services governance and managements systems. We saw evidence during our inspection that the area manager had been taking steps to achieve this aim.

The provider did not always work effectively to ensure people received safe care. At the time of our assessment the service was carrying out building works. Although a health and safety risk assessment for the building work had been completed this failed to detail and consider the impact the building work had on people using the service and advice had not been sought from dementia specialists on how to mitigate risk and manage the building work whilst supporting people living with dementia.

This meant important information about people's needs and risks were not shared with professionals to ensure better safe outcomes.

The provider and managers worked in partnership with GP, district nurses, a local hospice and the local authority’s multi-disciplinary team. The administrator told us the home manager regularly attended provider forums run by the local authority.

The provider did not have systems in place to focus on continuous learning, innovation and improvement within the service. The provider did not encourage creative ways of delivering equality of experience, outcomes and quality of life for people. They did not actively contribute to safe, effective practice and research. For example, there was poor oversight and a failure to investigate incidents, a failure to identify and manage risks to people and with the environment and fire safety within the service.