CQC report explained · a nursing home
What the CQC found at Swansea Terrace
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people did not receive medicines as prescribed, and some medicines were not in stock. Risks linked to repositioning, equipment and missed care alerts were not always managed safely.
- Effective?
- Requires improvement
- People were at risk of dehydration because fluid targets were not met. Some care records lacked detail, dietary information was inconsistent, and health records were not always updated.
- Caring?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Responsive?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify missed care, missed fluid targets or incomplete risk records. People's views and relatives' feedback had not been sought consistently.
What inspectors found, March 2024
Swansea Terrace was rated Requires Improvement; inspectors found risks with medicines, hydration, staffing and management oversight.
This was an unannounced focused inspection on 19 and 21 July 2023. Inspectors reviewed 14 care records and medicine records, spoke with people, relatives, staff and managers, and observed care and lunch.
The home was not always safe. Some people missed repositioning support or did not receive enough to drink. Medicines were not always available or managed safely, and diabetes care records were not reliable.
The home was also not always effective or well-led. Fluid targets were missed, some dietary choices were not properly supported, and care records and management checks were incomplete. The overall rating changed from Good to Requires Improvement.
Safe recruitment
The provider carried out the required checks before employing staff.
“The provider had robust recruitment procedures in place which helped ensure staff employed were suitable to work with people.” from the report
Clean environment
Inspectors found the home clean and tidy. Relatives also spoke positively about the cleanliness of bedrooms.
“The home was clean and tidy. Relatives told us they found the home was always well kept.” from the report
Building safety
Checks covering fire, gas, electrical safety and legionella were up to date, and identified work had been followed up promptly.
“Maintenance of the home, safety checks and procedures in relation to legionella, fire safety, electrical safety and gas safety were up to date.” from the report
Openness to improvement
The provider and interim manager cooperated with outside partners and began responding to the inspection findings.
“The provider and interim manager were open and cooperative with partners to learn and respond to concerns.” from the report
Medicines and diabetes care
seriousSome medicines were unavailable, records did not accurately show stocks, and information for staff about some medicines was missing. Diabetes care was inconsistent and one insulin regime was incorrect.
“Medicines were not managed safely. This placed people at risk of harm. This was a breach of regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Risks and missed care
seriousRepositioning support was not always provided or recorded accurately. Missed care alerts had built up without being acted on, and some equipment risk assessments lacked enough detail.
“Overdue alerts had built up and had not been responded to. We were not assured the missed activities had been responded to or picked up by managers.” from the report
Food and drink
seriousPeople needing support to drink did not meet their recorded fluid targets. The menu did not clearly provide options for specific dietary needs, including vegetarian and vegan choices.
“People had not been supported to maintain adequate nutrition and hydration. This meant they were at risk of harm. This was a breach of Regulation 14” from the report
Staffing pressure
needs fixingThere were mixed views about staffing, and some staff said they did not have enough time to meet all people's needs. The home was using many agency staff, including nurses.
“There were a high number of agency staff working in the home, including nurses. The provider was recruiting to permanent positions in the home and this was ongoing.” from the report
Management oversight
seriousAudits did not identify important problems with care, records and risks. Management changes and inconsistent feedback arrangements affected the consistency of care and communication.
“Oversight of the quality of care provided and care records had not been maintained. This placed people at risk of harm and was a breach of Regulation 17” from the report
- 01What has changed to ensure every person receives their medicines, including diabetes treatment and medicines prescribed when needed?
- 02How do you now check that people meet their individual fluid targets each day?
- 03How are repositioning and other missed care alerts reviewed and acted on promptly?
- 04How many permanent nurses and care staff are currently in place, and how do you ensure agency staff know each person's needs?
- 05What audits and feedback arrangements are now in place to identify problems and involve relatives?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 6 March 2024 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, December 2020
Swansea Terrace was inspected but not rated; inspectors found good infection control arrangements during a targeted Covid-19 review.
Inspectors visited on 9 and 14 December 2020. This was an announced, targeted inspection of infection prevention and control during the coronavirus pandemic.
They inspected a designated unit for six people. No one was living there at the time. The home had separated units, limits on movement, trained staff, PPE arrangements and safe visiting procedures.
Inspectors said they were assured about admissions, testing, shielding, social distancing, cleaning, hygiene and managing possible outbreaks. The report says the home met good infection prevention and control guidelines.
The service was inspected but not rated. This inspection did not provide a full rating for the home or ratings for most areas of care.
Safe admissions
The home had arrangements intended to admit people safely and reduce the risk of infection spreading between units.
“The systems in place allowed people to be admitted to the home safely.” from the report
PPE and training
Inspectors found that national guidance was being followed and staff had training in infection prevention and control.
“There was clear signage on the correct use of PPE and handwashing techniques and staff had received appropriate infection control and prevention training.” from the report
Visiting arrangements
Visits were managed through booking, health screening, social distancing and PPE. Video calls were also available.
“A detailed risk assessment was in place for ensuring safe visits, this included a booking system, to allow for social distancing, visitor agreement form, health screening and use of PPE.” from the report
Unit separation
Units were kept separate and staff and residents did not move between them, helping to limit cross infection.
“Each unit was separated to prevent cross infection. There was no movement of staff or residents between units.” from the report
Testing and outbreak planning
Inspectors were assured that testing was available and that the home had plans to prevent or manage outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the infection control arrangements described in this report being used now?
- 02How do you manage visits, including health screening, PPE, social distancing and alternatives such as video calls?
- 03How do you prevent staff and residents moving between units and spreading infection?
- 04How often are people using the service and staff tested, and what happens if someone tests positive?
- 05What are the current overall ratings for the areas that this targeted inspection did not assess?
This was an announced, targeted inspection of infection prevention and control in a designated six-person unit; no one was living there and the other care questions were not assessed. This explanation was written from the published report of 22 December 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 Swansea Terrace
6 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- March 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- February 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 30 August 2012.
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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85 live-in carers within about an hour of Lancashire
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 £980 to £1,260 a week. 78 can care for a couple. 11 years' experience on average.
“She understands the needs of an elderly person in the early stages of dementia and has treated my mother with great kindness and skill.”
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
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.