CQC report explained · a residential care home
What the CQC found at Swallow Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough suitably skilled staff, safer medicines systems, better risk assessments and improved safeguarding. Infection prevention arrangements were also found to be effective.
- Effective?
- Good
- Staff had received relevant training and people's care plans and needs assessments were up to date. Mental capacity assessments and applications for Deprivation of Liberty Safeguards were in place where needed.
- Caring?
- Good
- People received kind and respectful care. Staff supported privacy, dignity, choice and communication, and relatives said people were happy when using the home.
- Responsive?
- Good
- Care plans reflected people's individual needs and were reviewed regularly. People were supported with communication, relationships, interests and a range of social and cultural activities.
- Well-led?
- Requires improvement
- Leadership and the culture had improved, and audits were helping to identify problems. However, inspectors needed more evidence that the new systems and improvements would be maintained over time.
What inspectors found, March 2023
Rated Good overall, but Well-led Requires Improvement; inspectors found major progress after an earlier Inadequate rating and special measures.
This was an unannounced follow-up inspection on 23 November 2022. One inspector spoke with the manager and staff, contacted four relatives, observed care, and checked care plans, medicines records and other records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found improvements in staffing, medicines, risk management, training, care planning, communication, activities and people's privacy and dignity.
Well-led was rated Requires Improvement. The new manager had introduced effective audits and improved the culture, but inspectors said more time was needed to make sure these improvements continued. The overall rating changed from Inadequate to Good, and the home was no longer in Special Measures.
Safer staffing
Staffing levels were matched to people's assessed needs, including one-to-one support. Agency use was minimal and the home was recruiting more permanent staff.
“The home had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Medicines managed safely
People received medicines as prescribed. Staff had their competence checked, and care plans explained when people needed medicines prescribed for use as required.
“People received their medicines as prescribed with support from staff who were assessed as competent.” from the report
Kind and respectful care
Staff used calm, positive and respectful ways of communicating. The home had also taken steps to improve privacy in bedrooms.
“People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Personalised support and activities
Care plans reflected people's needs, preferences and communication methods. People could take part in activities matched to their interests, including arts and crafts and baking.
“People were supported to participate in their chosen social and leisure interests on a regular basis.” from the report
Improved openness
The new manager had introduced audits, encouraged staff to raise concerns and changed the culture so incidents and accidents were discussed more openly.
“The manager had put audits in place which had been effective in identifying concerns and areas for improvement.” from the report
Improvements not yet fully established
needs fixingThe main concern was whether the new audits and improvements would continue over time. Inspectors rated Well-led Requires Improvement for this reason.
“However, more time was needed to ensure the audits and improvements were sustained and embedded.” from the report
No registered manager at the visit
minorThere was no registered manager in post when inspectors visited. A new manager had been in post for three months, and the report says they were registered after the inspection.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What evidence can you show that the audits and improvements have been maintained since the inspection?
- 02How many permanent staff now work at the home, and how often is agency staff used?
- 03How will you record and review my relative's communication needs, including any use of pictures, signs or symbols?
- 04How will you involve our family in reviewing care plans and checking that they still reflect changing needs?
- 05What current arrangements are in place for mental capacity assessments and Deprivation of Liberty Safeguards where needed?
This was an unannounced follow-up inspection of the home, covering the five key questions and infection prevention and control, after the previous inspection found breaches. This explanation was written from the published report of 10 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2022
Rated Inadequate and placed in special measures; inspectors found widespread risks, poor care and serious failures in leadership.
This was an unannounced inspection on 29 April and 03 May 2022. Inspectors spoke with people using the home, relatives and staff. They reviewed care plans, medicine records, staff files and management records.
The inspectors found serious problems in every area. Risks, medicines, staffing, incidents, care planning and the building were not managed safely. People were sometimes left without enough support, activities or privacy. Some restrictions were used without proper plans or legal authority.
The home was rated Inadequate for Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found widespread and significant shortfalls, with people at risk of avoidable harm. The home was placed in special measures and the provider was required to submit an action plan.
Infection control
The home had effective arrangements for preventing and managing infection. Inspectors found the premises clean and hygienic and saw staff using protective equipment safely.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Familiarity with regular users
Staff showed a good understanding of people who used the respite service regularly and greeted people and relatives when they arrived.
“We saw staff had a good understanding of people who accessed the respite regularly.” from the report
Some food choice
Inspectors saw a menu offering choices, and records showed that people were sometimes supported to have a takeaway they chose.
“We saw a menu that offered choice for people and from daily notes we found on occasion people were supported to have a takeaway of their choice.” from the report
People at risk of harm
seriousRisk assessments and care plans were missing or out of date. Incidents, including incidents of a safeguarding nature, were not always recorded or reported.
“People were not kept safe from avoidable harm.” from the report
Unsafe medicines
seriousAntipsychotic medicines did not have the required as-needed guidance. Inspectors could not be assured that medicines were given appropriately.
“Medicines were not managed safely.” from the report
Insufficient skilled staff
seriousThe home relied heavily on agency staff, some of whom did not attend. Staff did not always have the skills or training needed for people's needs.
“The service did not have enough suitably trained and competent staff.” from the report
Poor dignity and privacy
seriousPeople were left without meaningful interaction and were not always treated respectfully. One bedroom had a full view of the bed through a glass wall without curtains.
“People were consistently treated with a lack of respect and dignity while they received care and treatment at the service.” from the report
Unlawful restrictions
seriousPeople were deprived of their liberty without the required legal authority. Records also lacked proper mental capacity assessments and best-interest decisions.
“People were being deprived of their liberty without the legal authority.” from the report
Limited activities and cancelled respite
needs fixingActivities were minimal and not personalised. Relatives said respite had sometimes been cancelled at very short notice because of staffing shortages.
“Opportunities for people to engage in activities were minimal.” from the report
- 01What immediate changes have been made to risk assessments, care plans and plans for restrictive practices?
- 02How do you now make sure every shift has enough suitably trained staff, including agency staff?
- 03What checks now ensure as-needed antipsychotic medicines are given only when appropriate and recorded with a clear reason?
- 04Have all required mental capacity assessments, best-interest decisions and liberty authorisations been completed?
- 05What evidence can you show that personalised activities, communication support and community access are now being provided?
This inspection covered all five key questions, the premises and care provided, as well as infection prevention and control; all five ratings deteriorated from Good at the previous inspection. This explanation was written from the published report of 11 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Swallow Lodge
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2014
Registered with the Care Quality Commission on 3 December 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.