CQC report explained · a residential care home
What the CQC found at Swanland House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care records were not always up to date, staffing levels were not sufficient at some times, and medicines were not always managed safely. Infection control was generally effective, but some chairs did not meet infection prevention standards.
- Effective?
- Requires improvement
- Staff did not understand the Mental Capacity Act well enough, training and supervision were inconsistent, and care plans did not always guide staff or reflect people's current needs. People did receive food, drinks and access to health professionals.
- Caring?
- Good
- This key question was not inspected during this visit. The report includes positive comments from people and relatives about staff being kind and helpful.
- Responsive?
- Outstanding
- This key question was not inspected during this visit.
- Well-led?
- Inadequate
- Leadership was inconsistent, managers' roles were unclear, staff did not feel listened to, and governance systems did not identify or address important concerns.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found serious leadership failings, unsafe staffing and medicines concerns, with an Inadequate rating for well-led.
The inspection was unannounced and took place on 07 June 2022 and 13 June 2022. One inspector visited, an expert by experience spoke to relatives by telephone, and inspectors spoke with people, relatives, staff and professionals. They reviewed care files, medicine records, staff records and the home's quality checks.
Inspectors found problems with risk assessments, medicines, staffing levels, mental capacity decisions and record keeping. They found that leadership and quality checks were not strong enough to identify or fix these problems. People were not always supported in the least restrictive way or in line with their best interests.
There were also positive findings. Staff understood safeguarding, infection control was generally managed well, people had access to food, drinks, outside space and health professionals, and some people and relatives said staff were kind. The overall rating fell from Good at the previous inspection in 2018 to Requires Improvement. Safe and Effective were Requires Improvement, while Well-led was Inadequate.
Safeguarding awareness
Staff had completed safeguarding training and knew how to report concerns.
“Staff had completed safeguarding training and told us they would report any concerns to senior members of staff or the registered manager.” from the report
Infection control
Inspectors were assured about most infection prevention arrangements, including PPE, testing, visiting and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Food and drinks
People were offered suitable food and drinks, including snacks and drinks outside mealtimes.
“People were supported to access food and drink that met their dietary needs and wishes and were offered a choice for each meal.” from the report
Access to healthcare
People could see health and social care professionals, and staff sought specialist advice when needed.
“People had access to a range of health and social care professionals to achieve the best outcomes for them.” from the report
Medicines
seriousMedicine records had gaps, stock balances were not recorded, some medicines were stored outside the recommended temperature range, and controlled drug records were incomplete.
“Eight people had gaps in their Medication Administration Records (MAR), we could not be sure if people had received their medication as prescribed” from the report
Risk management
seriousCare plans and risk assessments did not always reflect current needs or explain how staff should reduce risks such as falls and challenging behaviour.
“Care records were not kept up to date to reflect people's current needs.” from the report
Mental capacity and consent
seriousStaff had not been trained well enough in the Mental Capacity Act and one person's belongings were removed without the required capacity assessment or best-interest meeting.
“People were not supported in the least restrictive way.” from the report
Leadership and oversight
seriousQuality checks did not identify important problems, managers' responsibilities were unclear, and staff and relatives were not fully involved in running the home.
“The leadership, governance and culture did not promote the delivery of high-quality person-centred care.” from the report
Staff training and supervision
needs fixingSupervision, appraisals and training were inconsistent. CQC recommended that the provider review these systems.
“We recommend the provider reviews its systems and processes to ensure staff receive regular supervision and appraisals and are supported to undertake further training.” from the report
- 01How many staff are now deployed during the day and night, and how do you check that staffing matches people's changing needs?
- 02What checks now confirm that every person receives their medicines as prescribed and that medicines are stored at the correct temperature?
- 03How have you updated care plans and risk assessments for falls, challenging behaviour and other current risks?
- 04What Mental Capacity Act and Deprivation of Liberty Safeguards training have staff completed, and how are best-interest decisions recorded?
- 05What changes have been made to leadership, audits, incident reviews and communication with relatives since the inspection?
This inspection focused on Safe, Effective and Well-led; Caring and Responsive were not inspected during this visit, and the report says ratings for uninspected questions use the previous inspection ratings. This explanation was written from the published report of 12 August 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 2022
Inspected but not rated; inspectors found good COVID-19 arrangements, but some isolation practices and risk assessments needed review.
This was an unannounced, targeted inspection on 18 January 2022. It focused on infection prevention and control during COVID-19, and asked about staffing pressures.
Inspectors found that visits, protective equipment, testing, vaccination and infection control training were being managed in line with guidance. They were assured about most infection prevention arrangements.
Inspectors were only somewhat assured about the premises layout and hygiene practices. Some practices and risk assessments for isolating people needed review.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or a rated score for Safe.
Visits followed guidance
Visits were arranged in line with the government guidance in place at the time.
“Visits were arranged in line with government guidance.” from the report
Protective equipment
Staff were using personal protective equipment in line with government guidance.
“Staff were wearing personal protective equipment (PPE) in line with government guidance.” from the report
Testing and training
People and staff were included in regular testing, and staff had infection prevention and control training.
“People and staff were part of a regular testing programme.” from the report
Vaccination arrangements
Staff had received COVID-19 vaccination as a condition of working in the home.
“Staff had received the COVID-19 vaccination as a condition of their deployment.” from the report
Isolation arrangements needed review
needs fixingInspectors were only somewhat assured about the premises layout and hygiene practices. They said some isolation practices and risk assessments needed to be reviewed.
“Some practices and risk assessments in relation to isolating people required review.” from the report
- 01What changes have you made to the practices and risk assessments for isolating people since the inspection?
- 02How do you now check that the home's layout and hygiene practices support infection prevention?
- 03What measures are in place when COVID-19 creates staffing pressures, and how do you check they do not affect people's care?
- 04How are visits, testing and PPE arrangements being managed now?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it was not a full inspection and the service was not rated. This explanation was written from the published report of 4 February 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 Swanland House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: OutstandingWell-led: Inadequate
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015
Registered with the Care Quality Commission on 29 May 2015.
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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16 live-in carers within about an hour of East Riding of Yorkshire
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 £1,030 to £1,420 a week. 14 can care for a couple. 7 years' experience on average.
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
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.