CQC report explained · a residential care home
What the CQC found at Swan Hill House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicine records, storage and administration were not always safe. Other safety arrangements, including risk assessments, safeguarding training, recruitment checks and infection control measures, were generally found to be suitable.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Quality checks had not found important problems, staff competency monitoring was not effective enough and staff said they had not received regular supervision.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found medicine safety and management systems were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 28 February 2023, spoke with 11 people, two visitors and seven staff, and checked care plans, medicine records, recruitment files, training records and management records.
The home was not always safe. Medicine records, storage and administration had several problems, creating a risk that people might receive medicines incorrectly. People said they felt safe, and inspectors found suitable risk assessments, safeguarding training and recruitment checks.
The home was also not well-led. Audits had failed to identify medicine and environmental problems, and staff had not received regular supervision. The provider took immediate action on some issues and said further audits and checks had been introduced.
The overall rating changed from Good to Requires Improvement. This was a focused inspection of Safe and Well-led. The ratings for the other three questions were carried over from the previous inspection and were not reassessed.
People felt safe
People told inspectors they felt safe living at the home and with the staff supporting them.
“People told us they felt safe living at the home and with the staff who supported them.” from the report
Risk planning
Inspectors found risk assessments were regularly reviewed, and people had equipment and emergency plans to help reduce risks.
“There were effective procedures to assess and manage risks which staff understood and followed.” from the report
Safeguarding and recruitment
Staff had safeguarding training, and recruitment checks included references and DBS checks before staff started work.
“People were protected from harm because the provider followed safe procedures for the recruitment of staff.” from the report
Approachable managers
People and staff said the managers were approachable and responsive to requests.
“People and staff told us they found the registered manager and deputy manager approachable.” from the report
Medicine records
seriousRecords did not always show why an as-needed medicine had been given. This meant the home could not demonstrate that it had been administered appropriately.
“The lack of accurate records meant the provider could not demonstrate the medicine had been given appropriately.” from the report
Environmental checks
needs fixingAudits missed a dirty laundry floor, an unlocked cupboard containing potentially hazardous items and a bath hot water tap that did not work. The cupboard was made safe immediately.
“Audits and checks on the environment had failed to identify the dirty floor in the laundry room, a missing lock on a cupboard storing hazardous items and a bath hot water tap which wasn't working.” from the report
Staff supervision
needs fixingStaff said they had not had regular opportunities to discuss their role and performance. The deputy manager said supervisions would be re-introduced.
“Staff told us they had not received opportunities to discuss their role and performance through regular supervisions.” from the report
Staffing views
needs fixingPeople gave mixed views about staffing. One person said help with showers could be delayed by a day or two, although inspectors found no evidence that people were at risk of harm.
“I need help to have a shower but often there aren't enough staff on duty, and it can get pushed back a day or two.” from the report
- 01What exact changes have been made to medicine records, storage temperatures and as-needed medicine instructions?
- 02How do you now check that staff administer medicines exactly as prescribed?
- 03How often are medicine and environmental audits completed, and who reviews the results?
- 04Have regular staff supervisions restarted, and how are staff skills and medicine competence checked?
- 05How do you make sure people receive help with showers and other personal care without delays?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 5 April 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, February 2019
Rated Good overall, but inspectors found medicines were not always managed safely and rated Safe as Requires Improvement.
This was an unannounced inspection on 25 January 2019. One inspector spoke with people living there, a relative, staff, the cook, the manager and the provider. They also observed care, checked records and examined how medicines were stored and given.
People said they felt safe, received enough staff support and were treated kindly. Inspectors found good care, food, activities, healthcare support and management in most areas.
The main problem was medicines management. Some medicines were not dated when opened, stock records did not always match, some medicine administration records had gaps, and room temperatures were not always recorded. The overall rating stayed Good, but Safe fell from Good at the previous inspection to Requires Improvement.
Kind and respectful care
People said staff were kind and caring. Inspectors observed staff taking time to talk with people and involve them in conversations.
“People were treated in a kind and caring way by staff who demonstrated patience and compassion towards people.” from the report
Enough staff
People said there were enough staff to meet their needs. Staff knew people well and said they did not feel rushed.
“People told us that there were enough staff to meet their needs.” from the report
Personalised support
Care plans included people's likes, dislikes and preferences. The home supported activities, community links and, where important to people, their pets.
“Care plans contained details of people's preferences, likes and dislikes.” from the report
Approachable management
People, relatives and staff described the management team as approachable. The manager had systems for gathering feedback and acted on issues identified.
“People and their relatives spoke highly of the registered manager.” from the report
Medicine records and checks
seriousMedicine management was not consistently safe. Some opened medicines were not dated, stock numbers did not always match records, and some administration records were incomplete.
“Medicines were not consistently managed safely.” from the report
Medicine audit frequency
needs fixingThe home's audits did not always identify medicine errors quickly. Inspectors asked the manager to carry out more robust audits more often.
“We recommend that the registered manager undertakes more robust medication audits more frequently.” from the report
- 01Have the electronic medicines system and the planned more frequent medicine audits now been put in place?
- 02How do you check that opened medicines are dated and not kept beyond their safe period?
- 03How are medicine stock levels checked against the administration records?
- 04How do you make sure staff sign the medicine administration record every time a medicine is given?
- 05How do you record and monitor the temperature of the medication room?
This was a planned, unannounced inspection covering all five key questions; Safe changed from Good at the previous inspection, while the overall rating remained Good. This explanation was written from the published report of 27 February 2019 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 Hill House Residential Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Swan Hill House Residential Home →
- February 2019Goodstayed GoodSafe: Requires improvementWell-led: Good
Read what inspectors found at Swan Hill House Residential Home →
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 5 March 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
57 live-in carers within about an hour of Shropshire
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.
Most charge £960 to £1,230 a week. 52 can care for a couple. 9 years' experience on average.
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.