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 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 improved to good. This meant people were safe and protected from avoidable harm. we found breaches of Regulation 17 (good governance) of the Health and Social Care Act 2008 and Regulation 18 Care Quality Commission (Registration) Regulations 2009.

Breaches identified at the last assessment 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 have now been met.

Following that inspection the provider had implemented significant changes which resulted in improvements in all areas previously in breach. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.
 

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

At the last inspection we identified the need for the provider to develop and strengthen a refreshed shared vision and the provider’s strategic objectives with staff. We saw this had been achieved from our discussions with staff.

Staff told us they felt happy and supported working at the service. Comments from staff included, “We know what is expected of us and we all work together as a team,” “Our aim and that of the management is clear. It is to give the residents the best care possible,” “We are here to provide people with a comfortable home and provide good, safe, dignified and respectful care,” and “We all try to help people to enjoy every day and to maximise their independence so they get the best quality of life they can.”
 

At the last inspection the registered manager failed to notify CQC of statutory notifications and this was found to be a breach of Regulation 18 Care Quality Commission (Registration) Regulations 2009. At this inspection we found all the necessary reporting from the provider to CQC had been carried out as required and the provider was no longer in breach of this regulation.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered provider was also the registered manager for the service however they employed a home manager to run the service. The home manager told us they had applied to the CQC to become the registered manager for the service.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
A person using the service told us, “I think this is a very good place, the staff work well together. The staff are very nice, they think of you. They listen to me and they understand all the things I need.” Regular staff meetings took place to support and guide staff with best practice. One staff member told us, “The team meetings are good we are able to voice our opinions.”
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider supported staff to feel included and treated them with equity, taking account of their individual needs. A staff member told us, “The manager arranges cultural days for staff and residents. They are respectful of people’s different religions and backgrounds. As a team we talk about protected characteristics, and I am open to support people and colleagues from different backgrounds.”
 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At the last inspection the provider’s quality assurance processes were found to be ineffective. They did not identify areas of practice that needed improvement and were the provider was unable to learn from information gained from the quality assurance audits that were in place then. Since that inspection the provider has implemented a new auditing process that is effective and comprehensive. It has enabled the provider to make the service improvements that were necessary. The provider is no longer in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The manager and the staff understood their roles and responsibilities in relation to assessing, monitoring and managing the quality and safety of the care provided. The manager told us they carried out regular safety and quality monitoring checks on staff working practices in the home. We saw evidence that supported this. A member of staff told us, “Managers carry out regular checks on our working practices. These checks help us ensure we maintain the high standards of care that is expected.”

Internal audits checked people’s records to see that tasks were completed and well-managed. They covered staff training and support, administering prescribed medicines, and dealing with complaints and safeguarding incidents.

The outcome of all the audits and checks were routinely analysed which helped the provider to identify issues and learn lessons about what they could do better. The managers understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Timely notifications were made to the CQC.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider and managers worked effectively in partnership with health and social care organisations. These included the GP, district nurses, speech and language therapists and the local authority’s multi-disciplinary team including the falls team. Health professionals such as the GP, district nursing team and pharmacist who we spoke with confirmed this. Comments included, “We work well together, they [the provider] keep us well informed as to people’s progress and where we are needed, we go to the home fully informed and work in a well co-ordinated way that helps ensure the best outcomes for people.
 

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had implemented effective procedures regarding reporting and learning from when things went wrong. The manager told us they carried out regular checks of the quality and safety of people's care and we saw evidence that supported this. It included checks of the environment and equipment used for people's care and checks on medicines and care plans. Regular checks were made of any accidents. They were also carried out for people's health and nutritional status and any related incidents, such as weight loss, infection or skin sores. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care.

At the last inspection the provider did not have a service improvement plan. Since that inspection the provider has significantly improved it’s quality assurance processes, including a service improvement plan. This development plan included actions that came from the provider’s audits, quality assurance processes and feedback. All action points had a target completion date and identified the staff member responsible for them. We noted this system had been effective in driving improvements, such as improving the mealtime experience.