Sway Place

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.

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 the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance. Systems were either not in place, or not operating effectively as they had not identified the shortfalls found at this inspection.
 

This service scored 61 (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 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.

Managers and staff actively sought the views of people and their families through individual meetings, surveys and telephone calls. Relatives told us they were included, “The new manager is lovely and I have every confidence he will turn the place around, I can talk to him anytime” and, “If we have any issues they are quickly resolved.”

The desire to change culture was highlighted by the manager, but change has not yet been embedded. The provider acknowledged this was an ongoing area for development due to historical management changes.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. Staff did not share an understanding of the risks and issues facing the service and were not always clear about their responsibilities. Reporting of incidents, risks, issues and concerns was unreliable or inconsistent . Cover for absent managers had not ensured consistent leadership, and staff told us policies and procedures were not always embedded into daily practice. However, during the inspection, the newly appointed registered manager demonstrated a good understanding of CQC requirements and confirmed the work in progress to improve the management of adverse events, this included building relationships with the local authority’s safeguarding team.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Not all staff knew how to raise concerns or who to report incidents to externally . The management team was newly established and acknowledged to staff systems in place required improving to become effective. The home manager had apologised to staff in team meetings about the lack of support in place and outlined ways communication to raise concerns and celebrate successes would be improved.

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

Staff and relatives told us, in the past leaders had not always encouraged staff to share ideas for improvement and innovation or actively invested time to listen and engage. However, there was a strong sense of trust developing between new leadership and staff. Comments from staff included, “I do feel proud to work for sway place The home feels warm, inviting and full of life” and, “I have been made to feel very welcome and part of the team. No question is too small or silly that I feel like I can’t ask.”

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Governance, management and accountability arrangements were not reliable or effective. Quality assurance arrangements were not applied consistently and were ineffective. The provider shared an audit completed in October 2024 which identified staff needed “prompting around external reporting agencies / protocols.” Management systems were in place to drive improvements. However, these had not identified and managed risks to the safety and quality of the service found at this inspection. Actions to introduce improvements were reactive, not applied widely and consistently across the service. This meant people were at increased risk of avoidable harm as best practice was not embedded in all aspects of service delivery.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

People and their relatives told us they are able to attend meetings at the service.

Health and social care professionals told us they worked together with the staff and manager as partners.

The manager worked very proactively in creating partnerships with health and social care professionals, and organisations providing access to community services. Leaders at Sway Place were especially proud of how their dementia café has grown. The service extended an invitation to members of the public to attend an open session of reminiscence and music, and shared photos with inspectors of how attendance has increased by word of mouth in the local community.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Areas for improvement were not always identified, and where they were, action was not always taken and shortfalls were not always rectified in a timely way. For example, a concern regarding a safe evacuation during a fire drill had not been addressed and continued to be recorded as a concern until we identified it during the inspection. Therefore, lessons learnt had not always been effectively shared with all staff to prevent re-occurrence.