CQC report explained · a residential care home
What the CQC found at Swan Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, recruitment, training, safeguarding and medicines were generally safe. However, staff COVID-19 testing was not consistently monitored, and some care and environmental risks were not fully managed.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The home had quality checks and a new manager had made improvements, but the checks did not identify several infection and environmental risks. The systems were not robust enough to demonstrate that safety was being managed effectively.
What inspectors found, April 2022
Requires Improvement; inspectors found safe staffing and kind care, but infection-control checks and wider governance were not reliable enough.
This was a focused inspection on 30 and 31 March 2021. Inspectors looked mainly at Safe and Well-led after concerns about infection control and people's care. They spoke with staff and relatives and checked care, medicines, recruitment and quality records.
The home had enough staff, safe recruitment, suitable training and safely managed medicines. Relatives generally said people were safe, and staff were seen spending time with people. However, checks on staff COVID-19 testing were not effective, and some environmental risks were missed.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. The service had held this rating at the previous inspection, published in February 2020. The report says the new management responded quickly to many concerns, but the CQC found a breach of Regulation 17 and served a warning notice.
Enough staff
Inspectors found enough staff on duty to keep people safe. Staff were described as unhurried and able to spend time with people.
“There were enough staff on duty to keep people safe.” from the report
Safe recruitment
The required checks were completed before staff were appointed.
“Staff were recruited safely; appropriate checks were carried out before staff were appointed.” from the report
Medicines
Medicines records showed people received their medicines as prescribed, and staff had training and competency checks.
“Medicines administration records showed people received their medicines as prescribed” from the report
Person-centred care
Staff described care that was tailored to each person and supported people according to their wishes.
“You are providing the level of care tailored to that person, to how they would want it, everything revolves around them” from the report
Responsive management
The new management was viewed positively by staff and relatives, and acted quickly on many issues raised during the inspection.
“The registered manager took immediate steps to address most of the concerns raised during the inspection.” from the report
COVID-19 testing checks
seriousMonitoring of staff testing was not effective. Some staff did not take part in testing, and the home had not robustly managed the possible infection risk.
“Systems for monitoring of staff testing for Covid-19 were not always effective.” from the report
Missed environmental risks
seriousQuality checks did not identify that part of the garden needed urgent cleaning or that a PPE bin had no lid. Inspectors said these created possible health and safety or infection risks.
“The provider had failed to implement regular checks and during the inspection the garden area needed urgent cleaning.” from the report
Incomplete care and safety records
needs fixingOne fire evacuation plan did not cover all aspects, and one support plan did not fully reflect current care needs. The manager said these would be updated.
“A person's fire evacuation plan had not considered all aspects of the plan fully.” from the report
Quality systems
seriousThe home's audits and checks had not found several problems before the inspection. Inspectors said this placed people at risk of harm, although there was no evidence anyone had been harmed.
“We found no evidence that people had been harmed however, systems were not robust enough to demonstrate safety was effectively managed.” from the report
- 01How do you now record and follow up staff COVID-19 testing, including refusals to test?
- 02What action plan was provided after the Regulation 17 warning notice, and what improvements have been checked since?
- 03How do you make sure garden cleaning, PPE disposal and other environmental risks are found through daily checks?
- 04Have the fire evacuation plan and all support plans been fully updated, and when were they last reviewed?
- 05What changes have been made under the new management to improve people's progress and avoid people becoming bored?
This was a focused inspection of Safe and Well-led following concerns about infection control and people's care; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 23 April 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.
What inspectors found, February 2020
Swan Court was rated Requires Improvement; inspectors found gaps in medicines management, care records and checks on quality and safety.
This was an unannounced, focused inspection on 7 and 8 January 2020. Inspectors looked only at Safe and Well-led after concerns were raised about safety and care. They spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was not always safe. Some staff were unclear about emergency medicines, liquid medicines did not always have opening dates, and guidance for medicines given when needed was not always clear. Care records were not always updated after people's needs changed.
The home was not always well-led. Audits had not found or resolved some problems, incident records were not analysed for wider patterns, and families were not regularly asked for their views about the service as a whole. There were also gaps in fire equipment checks.
The overall rating fell from Good at the previous inspection, published on 7 November 2018, to Requires Improvement. The other three question ratings were carried forward from the previous comprehensive inspection because they were not inspected this time.
Safe recruitment
Recruitment checks were described as robust and staff were considered suitable to work with vulnerable people.
“Staff were recruited safely. Robust pre-employment checks were carried out to ensure staff were suitable to work with people who may be vulnerable.” from the report
Enough staff
Relatives said there were enough staff to meet people's needs. Agency staff were used when permanent staff were absent.
“Relatives told us there were sufficient staff to meet people's needs.” from the report
Safeguarding awareness
Staff understood signs of abuse and knew how to report concerns. Relatives said safeguarding concerns were reported.
“People were supported by staff who understood the signs of abuse and appropriate action to take should they have concerns.” from the report
Positive management relationships
Relatives and staff spoke positively about management and said they could raise concerns.
“Staff and relatives spoke positively about the management at the service and felt able to raise concerns.” from the report
Medicines were not always managed safely
seriousDifferent emergency medicine protocols were in use and not all staff were clear about the correct process. Some liquid medicines had no opening date, and guidance for medicines given when needed was incomplete.
“Liquid medicines we reviewed did not have a date of opening. This meant staff did not know when the medicine was no longer safe to use.” from the report
Care records were out of date
needs fixingRecords were not always updated promptly after changes in people's needs or after incidents. This increased the risk of inconsistent care, especially when agency staff were used.
“Care records were not always updated in a timely manner following changes in need.” from the report
Quality checks did not pick up problems
needs fixingAudits did not identify some medicine issues, and action was not always taken promptly when problems were found. There was also a six-month period when some fire equipment checks were not recorded.
“Systems in place to ensure medicines were safely managed needed improvement.” from the report
Incident learning was limited
needs fixingThe home dealt with individual incidents but did not look for wider themes or trends that could reduce future risks.
“Although incidents were recorded and measures put in place to reduce risk and improve the quality of care for people, there was no oversight or analysis of the incidents within the service.” from the report
Families had limited involvement in the service as a whole
minorRelatives were involved in individual care decisions, but there were no regular meetings or other regular ways to gather their views about the wider service.
“There were no regular meetings or other ways to gather their views.” from the report
- 01What has been done to make sure every staff member follows the correct emergency medicine protocol?
- 02How are liquid medicines now dated when they are opened, and how are medicines given when needed explained to agency staff?
- 03How quickly are care plans and risk assessments updated when a person's needs change or an incident occurs?
- 04How are fire equipment checks recorded and reviewed so that another six-month gap does not happen?
- 05How are incidents now analysed for repeated themes, and how are families regularly asked for their views about the service?
This was a focused inspection of Safe and Well-led only; the other three question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 12 February 2020 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 Swan Court
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2018GoodSafe: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 10 May 2017.
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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