CQC report explained · a residential care home
What the CQC found at Swarthmore Housing Society Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were sometimes missed, misunderstood or not recorded clearly. Risk assessments and repositioning records were not always complete, and one person’s mattress was not set correctly.
- Effective?
- Requires improvement
- Some assessments and care plans did not reflect people’s current health needs. Records did not always show that required checks had taken place, although staff training, food choices and healthcare referrals were positive.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people to make choices and remain as independent as their condition allowed.
- Responsive?
- Good
- Staff knew people well and relatives were involved in care planning and reviews. There was a wide range of activities, support for communication needs and an appropriate complaints process.
- Well-led?
- Requires improvement
- Management audits had not identified important problems with medicines, risks, mattress settings or care records. The home had an open culture and good links with health professionals, but its systems for checking quality were not effective enough.
What inspectors found, October 2019
Swarthmore Housing Society Limited was rated Requires Improvement; inspectors found kind and responsive care, but serious problems with medicines, risk records and management checks.
Inspectors visited without notice over three days. They spoke with people living at the home, relatives, staff and health professionals. They observed care and reviewed care plans, medicines records, staff files and management records.
People were treated with kindness and respect. They had choices about daily life, food and activities. The home supported hobbies, community links and end of life care. Staffing levels, cleanliness and recruitment checks were also satisfactory.
However, medicines were not always given or recorded safely. Risk assessments and care records were sometimes missing, out of date or conflicting. Management audits had not found these problems. The overall rating fell from Good at the previous inspection to Requires Improvement.
Kind and respectful care
People and relatives spoke positively about the care. Staff respected privacy, dignity, equality and personal choices.
“Staff were caring and respected people as individuals.” from the report
Activities and community links
People could follow hobbies and join varied activities, including trips, exercise, lessons and entertainment. One-to-one activities were available.
“The activities coordinator provided a varied programme of events and entertainment throughout the week.” from the report
Staffing and cleanliness
Inspectors found enough staff to meet people’s needs. The home was clean and staff had access to protective equipment.
“We concluded there were enough staff to ensure people's needs were met.” from the report
Choice and legal decision-making
Staff supported people to make their own decisions where possible and used best-interest decisions when needed. People had choices about food and daily activities.
“People were supported to have maximum choice and control of their lives” from the report
Medicines were not always safe
seriousSome medicines were not given, could not be located or were recorded with missing signatures. Staff also misunderstood one person’s pain relief instructions, and another person’s laxative was left unsecured.
“Medicines were not always managed safely and according to best practice.” from the report
Risks were not fully assessed
seriousSome people did not have complete risk plans. Inspectors found problems with a pressure-relieving mattress, repositioning records, choking guidance and self-medication checks.
“The provider did not always have risk assessments in place for people using the service which included plans for managing risks.” from the report
Care records were inaccurate
seriousSome care plans did not reflect people’s current conditions and contained conflicting information. Records did not always show that required checks or support had been provided.
“Records were not accurate complete and contemporaneous in relation to care delivery.” from the report
Management checks missed problems
seriousThe home’s audits had not identified the safety and recording issues found during the inspection. Incident records were completed, but the home did not analyse them for patterns or recurring falls.
“Audits completed by the registered manager were ineffective; they had not identified the concerns we found during the inspection” from the report
- 01What has changed to make sure every medicine is available, given as prescribed and recorded correctly?
- 02How do you now check that risk assessments cover choking, self-medication, pressure damage and repositioning?
- 03How do you make sure care plans are updated when someone’s health or support needs change?
- 04What new audits or checks are in place to find problems before they affect people?
- 05How do you analyse accidents, incidents and falls, and what action do you take when patterns appear?
This was an unannounced planned inspection of the care home covering all five CQC questions, including both the premises and the care provided. This explanation was written from the published report of 9 October 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.
What inspectors found, January 2017
Swarthmore Housing Society Limited: Rated Good overall, with kind and safe care, but improvements were needed with meals and staff supervision.
This was an unannounced inspection on 5 and 6 December 2016. Inspectors spoke with people living in the home, staff, volunteers and health professionals. They examined care, medicines, recruitment and other records, and observed care being provided.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Effective was rated Requires Improvement. Inspectors found gaps in guidance for some medicines, inconsistent staff supervision, and poor practice around people's choice, dignity, comfort and positioning during meals.
Inspectors also found kind and respectful staff, comprehensive care records, suitable activities, safe moving and handling, and a manager who was open to advice and working on improvements. The home had recently managed an outbreak of diarrhoea and vomiting, using agency staff to cover absences.
Kind and respectful care
People described staff as caring and kind. Inspectors saw patient and reassuring support, including when someone became distressed.
“People told us and we observed staff were caring and kind.” from the report
Safe care planning
Care records included risk assessments and plans for moving and handling, pressure injuries and nutrition. Staff used safe techniques when transferring people.
“Care and support was planned and delivered in a way that ensured people's safety and welfare.” from the report
Activities and inclusion
The home offered regular activities, trips and individual visits. People who rarely left their rooms were visited, helping them stay involved.
“There were activities most mornings and afternoons including twice-weekly exercise classes, reminiscence, games, music, poetry, talks and flower arranging.” from the report
Open management
Staff said the manager was approachable and they could raise concerns. Audits and an improvement plan were being used to improve the service.
“A number of audits took place at the home. These were used to assess the quality and the safety of the service provided.” from the report
Incomplete medicine guidance
needs fixingSome instructions for as-required medicines did not clearly explain when to give them, how often to give them, or what result to expect. Work was under way to improve this.
“We found some gaps in the guidance information for staff for "As required" medicines.” from the report
Choice and comfort at mealtimes
needs fixingInspectors saw a person served food in a way they had not chosen and left in a poor position for eating. The report recommended advice on person-centred care.
“This meant staff were not taking into consideration people's safety and comfort during meal times.” from the report
Staff supervision
needs fixingRecords did not always match the home's policy. Some staff had gone several months without the supervision the policy expected.
“We found one staff member had not received supervision for 9 months and another for 7 months.” from the report
Pressure on staffing
minorA recent infection outbreak led to staff absences and the use of agency staff. Some people said they sometimes waited for support, although the manager was checking call response records.
“However, the same person told us in the evening they could wait up to 20 minutes for support from staff.” from the report
- 01What changes have been made to ensure people choose how their food is presented and are positioned safely and comfortably during meals?
- 02How are as-required medicines now explained in staff guidance, including when they should be given and how staff judge whether they have worked?
- 03How often do staff now receive supervision, and how is this checked against the home's policy?
- 04What were the usual staffing levels after the recent sickness outbreak, and how quickly are call bells answered now?
- 05How are meal choices shown to people who have dementia or difficulty understanding the written menu?
This was an unannounced inspection of the overall service, including all five key questions, with observations, discussions and checks of care, medicines, recruitment and management records. This explanation was written from the published report of 10 January 2017 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 Swarthmore Housing Society Limited
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- October 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Swarthmore Housing Society Limited →
- January 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Swarthmore Housing Society Limited →
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 12 November 2010.
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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