CQC report explained · a nursing home
What the CQC found at Swarthdale Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Swarthdale Nursing Home was rated Inadequate; inspectors found serious safety and management failures despite some kind and respectful care.
Inspectors made an unannounced visit on 24 and 25 April 2023. They spent two days observing care, spoke with five people and nine staff, and reviewed care plans and service records.
They found people were at risk because safety risks, medicines, infection control, health monitoring and incidents were not managed reliably. Care records were often incomplete or inconsistent, and staff training and support had important gaps.
Staff were often kind, caring and respectful. The home was clean, people had some choice over meals, and the building had adaptations for people with dementia and mobility needs. However, activities, involvement in care, end of life planning and complaints handling were not good enough.
The overall rating fell from Requires Improvement in August 2022 to Inadequate. The home was placed in special measures, and the regulator required an action plan and said it would monitor progress and normally reinspect within six months.
Kind and respectful staff
Inspectors saw staff treating people with kindness, compassion, dignity and respect. People also said staff were kind and looked after them well.
“We saw staff spoke to people kindly, with compassion, dignity, and respect.” from the report
Clean environment
People's rooms and shared areas were clean during the inspection. Inspectors also saw some appropriate use of protective equipment.
“The home was clean, including people's rooms and public areas.” from the report
Meal choices
People were included in choosing meals and could ask for an alternative. Catering staff kept records of people's food preferences.
“People told us staff gave them choices for meals, and they could request something if they did not want what was on the menu.” from the report
Safe recruitment checks
The provider carried out recruitment checks in line with national guidance.
“The provider had carried out recruitment checks in line with national guidance.” from the report
Some building adaptations
The home had lifts, grab rails, handrails and dementia-friendly signs. People's rooms could be personalised.
“There were numerous adaptations and design features to assist people living with a dementia.” from the report
Unmanaged safety risks
seriousFire arrangements, gas safety, Legionella checks, asbestos information, equipment checks and hot water safety were not up to date. One person reported that their shower was very hot.
“Risks to people's safety had not been managed effectively.” from the report
Unsafe medicines systems
seriousStaff were not consistently using the electronic medicines records, audits were missing and a missing controlled drugs incident had not been properly recorded, reported or investigated.
“Medicines were not managed safely.” from the report
Incomplete care and health records
seriousCare plans and monitoring records did not always reflect people's current needs. Important information about nutrition, swallowing, mobility, temperature and changing health needs was missing or inconsistent.
“Care plans had not always been reviewed and information on paper care plans did not always match electronic care plans.” from the report
Limited activities and involvement
needs fixingPeople said they did not have enough to do. There was no effective cover for the activity coordinator, and people were not consistently involved in planning their care or activities.
“People told us they did not have enough to do.” from the report
Poor end of life planning
seriousEnd of life care plans did not consistently record people's wishes, and not all necessary staff had training to use syringe drivers.
“End of life care was not well planned.” from the report
- 01What specific actions have you completed to make fire safety, gas safety, hot water, Legionella and equipment checks safe and up to date?
- 02How are medicines now checked, including electronic records, controlled drugs and medicines given covertly or in crushed form?
- 03How do you make sure care plans and risk assessments are reviewed promptly when a person's needs change?
- 04What activities are now available in the evenings and at weekends, and how are people involved in choosing them?
- 05How are complaints, safeguarding concerns and staff concerns now recorded, investigated and used to make improvements?
This began as a focused inspection of Safe and Well-led because of concerns, but was widened to a comprehensive inspection covering all five key questions. This explanation was written from the published report of 21 July 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, August 2022
Rated Requires Improvement; inspectors found risks were not always managed and the home’s quality checks were not effective.
This was an unannounced focused inspection. Inspectors visited on 20 July 2022 and gathered further views from relatives and staff until 1 August 2022. They spoke with people, relatives, staff and managers, observed care, looked around the home and checked care, medicines, staffing and management records.
The home was not always safe or effective. Some risks, including weight loss, choking and changing health needs, were not recorded or reviewed properly. Some staff training was out of date, although there were enough staff to provide care and the manager started urgent improvements during the inspection.
The home was also not well-led because the provider had not kept proper oversight while the registered manager was absent. The overall rating fell from Good at the previous inspection in 2018 to Requires Improvement. Caring and Responsive were not inspected in this focused visit, so their previous ratings carried over.
Medicines
People received their medicines as needed, and staff handling medicines had been trained. Medicines were stored securely.
“People received their medicines as they needed. Staff who handled people's medicines had been trained to do so safely.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infections, including safe visiting, testing and hygiene arrangements.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Person-centred care
The manager and staff were described as committed to person-centred care. Relatives said staff were kind and caring.
“The manager and staff were committed to providing people with person-centred care.” from the report
Action after inspection
The interim manager acted quickly after concerns were identified, reviewed care records and produced an action plan.
“The manager took prompt action during and following our inspection to improve the safety of the service.” from the report
Risks were not managed
seriousSome people were put at risk because safety information was incomplete or out of date. Weight monitoring and records about thickener were not always adequate.
“People and their relatives told us they were confident people were safe, however some people had been placed at risk of harm because risks to their safety had not always been identified and managed appropriately.” from the report
Care records were not current
needs fixingCare was not always reassessed promptly when people’s needs changed. One person had significant unplanned weight loss without a proper review of their care.
“Although people's needs were assessed, their care was not always reviewed as their needs changed.” from the report
Weak quality oversight
seriousThe provider did not identify problems through its own monitoring while the registered manager was absent. Staff said they had raised concerns before the interim manager arrived.
“The provider had not maintained oversight of the quality and safety of the service during the registered manager's absence.” from the report
Staff training gaps
needs fixingSome training was out of date and some staff had not received a robust induction. The manager had started arranging updated and mandatory training.
“The manager had already identified issues with staff training. They had found some staff training was out of date and some staff had not received robust induction training when they were employed to work in the home.” from the report
- 01How have you checked that every person’s risk assessments and care records are now up to date when their needs change?
- 02How are you monitoring people’s weights and responding promptly to unplanned weight loss?
- 03How do you record the amount of thickener added to each person’s drinks, and who checks these records?
- 04Which staff training was out of date, and has all required training and induction now been completed?
- 05What progress has been made against the action plan, and how is the provider checking the home’s quality and safety?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 26 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.
Every inspection of Swarthdale Nursing Home
4 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- July 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 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.
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