Sway Place

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 outstanding (published 17 November 2021). At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.
 

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had procedures for the investigation, review and response to complaints, incidents and accidents. We identified instances the provider’s procedures had not always been followed. For example, incident forms of adverse events had not always been completed, and improvement actions identified were marked as complete even though records did not reflect lessons had been learnt or communicated with staff at Sway Place. This placed people at risk of increased harm through a recurrence of adverse events.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They ensured there was continuity of care, including when people moved between different services.

People’s support needs were detailed within their care plans and risk assessments on the electronic system. An emergency pack was available if people went into hospital or moved to another care home, this supported continuity of care for people.

A health and social care professional told us, “Staff at Sway Place are responsive in meeting residents’ needs and have always taken on board suggestions and recommendations to improve wellbeing.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service did not always share concerns quickly and appropriately. The manager provided evidence recent safeguarding concerns had been reported promptly to the relevant external agencies, in line with legislation. The provider informed us 92% of staff had completed mandatory safeguarding training, however staff told us they were unsure who to report concerns to externally and only identified concerns could be shared with the registered manager. Staff did not state they could report concerns to the provider, or name other professional organisations such as the local authority or police. People told inspectors what being safe meant to them and knew who to report concerns to if they did not feel safe. A relative commented, “The management team are more visible, it allows staff contributions to be appreciated and an opportunity for issues to be resolved quickly.”

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s records included a range of risk assessments related to a person’s health and wellbeing, however these did not always reflect all the risks identified.

Risk assessments, or guidance, was not always in place to help mitigate risks to people in relation to potentially flammable creams, or the risk of choking. This meant staff were not provided with sufficient information about how to support people safely.

The provider took action to address our concerns during the inspection and at the end of day 2, we saw 1 example of a completed risk assessment. The provider stated these would be implemented for each person as needed.

Staff told us about daily tasks completed to keep people safe. These included equipment safety checks and visual of the environment and reporting any concerns identified so these could be rectified.

The service did not always detect and control potential risks in the care environment. They did not always ensure equipment, facilities and technology supported the delivery of safe care. The provider’s systems in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria, like legionella, were not robust. Not all required works following a risk assessment had been completed as not all areas of the building could be accessed. Following our site visit the provider responded to us detailing action they would take and by when to ensure all remedial works were concluded. Environmental checks and maintenance were completed. We saw there had been regular checks to ensure the home was safe in the event of a fire and emergency, however not all actions identified by the provider had been completed. Following the inspection, the registered manager provided assurances additional training had been completed and updated guidance had been issued to all staff.

The service did not always ensure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together effectively to provide safe care that met people’s individual needs. The service’s recruitment process had not always been followed. Two out of three files we looked at did not contain the correct information required. Audits of recruitment files had identified shortfalls, but there was no evidence this had been addressed in the identified files or the process. Additionally, training requirements described in the job description had not always been achieved. There were inconsistent responses from the provider regarding what action would be taken to ensure staff would obtain training identified by the provider as necessary for the role. The provider told us all senior staff would be enrolled on a qualification, then later informed us this was not “policed nor is a requirement when recruiting.” However, this qualification was identified by the provider as an essential requirement in the job description for the role. This meant checks to ensure safe recruitment of staff were not robust and the provider could not be assured staff had the appropriate training, skills and knowledge, as outlined in their policies, to the safe care of people living at Sway Place. Feedback from staff highlighted, “a lack of supervision and support due to changes of managers at the home.” However, staff were optimistic about the approach of the new registered manager, informing us “the new manager seems supportive and is interested in the residents.”

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were not always supported by effective infection control practices. We observed communal bathrooms were not always clean. We identified build-up of limescale in a number of bathrooms throughout the service, this placed people at increased risk of water-borne infections like Legionnaires’ disease. This had not been identified by the service’s cleaning audits. Following our site visit, the home manager provided evidence of deep cleaning and maintenance tasks undertaken to improve the overall cleanliness of the service.

People and their relatives were mostly satisfied with the cleanliness of the premises and told us they saw staff wearing personal protective equipment (PPE) when working around the service. Staff told us they had access to PPE.

The service had not always ensured that medicines and treatments were managed safely and met people’s needs, capacities and preferences. The provider had a medicines policy, however this was not always followed. During the inspection, we were told following a medicine incident, all staff involved had a competency check to reduce risk of recurrence. These competency assessments were not readily available when requested. When located, 1 competency check viewed was not complete but was signed off by the provider. This meant people were at risk of not receiving medicines from staff who were appropriately trained and competent. In response to inspectors identifying this shortfall, the provider reviewed competencies of all senior staff during our site visit. Medicines were ordered, stored at the correct temperature and disposed of securely. Medicines records showed that they were given as prescribed for people. We observed staff giving medicines safely and asking if any ‘when required’ medicines were required. We observed people’s individual preferences for how they liked to take their medicines were respected by staff.