CQC report explained · a residential care home
What the CQC found at Swillbrook House Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe medicines management, suitable recruitment checks, appropriate risk assessments, enough staff and effective infection control arrangements. People said they felt safe and received help quickly.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Well-led?
- Good
- Inspectors found approachable management, regular audits and checks, feedback from people and staff, and action taken when improvements were needed.
What inspectors found, May 2022
Swillbrook House Residential Home was rated Good after improvements, with safe care and stronger management systems found.
This was an unannounced focused inspection. Inspectors visited on 10 and 11 May 2022, with inspection activity ending on 12 May. They spoke with four people using the service, two relatives and seven staff, and reviewed records and systems.
The home was rated Good for Safe and Well-led. Inspectors found that medicines, recruitment, risk assessments and infection control were managed safely. People said they felt safe and staff responded quickly when help was needed.
The inspection followed an earlier Requires Improvement rating. The provider had acted on previous recommendations about medicines, individual risks and recruitment records. The overall rating changed from Requires Improvement to Good, but only Safe and Well-led were inspected during this visit.
Medicines were safer
Staff gave medicines when needed, stored refrigerated medicines safely and had their competence checked.
“Staff administered medicines to people when they needed them.” from the report
Risks were assessed
The home used an electronic record system with risk assessments covering areas such as falls, nutrition, skin integrity and equipment.
“For example, risk assessments in nutrition, skin integrity, falls and the use of equipment were completed and reviewed.” from the report
People felt safe
People and relatives told inspectors that the home was safe. Staff said they knew how to recognise and report possible abuse.
“A relative told us they considered their family member to be safe.” from the report
Management listened and improved
The provider used audits, surveys and meetings with staff to identify improvements and share learning.
“The provider carried out a range of checks and audits to assess what was going well and where areas required improvement.” from the report
No registered manager was in post
minorThe report says there was no registered manager at the time of the inspection. A manager was in post and was completing the CQC registration process.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Has the manager now completed the process to become registered with the CQC?
- 02How are medicines checks and staff competency assessments kept up to date?
- 03How often are each resident's risk assessments reviewed, including falls, nutrition and skin integrity?
- 04What changes came from the current review of information about people's dietary needs?
- 05How are feedback, audits and staff meetings used to check that improvements continue?
This was an unannounced focused inspection of Safe and Well-led; Caring, Effective and Responsive were not inspected and their ratings carried over from the last inspection. This explanation was written from the published report of 20 May 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, July 2021
Rated Requires Improvement; inspectors found kind care and prompt action, but medicines, care records and management checks were not consistently safe.
This was an unannounced focused inspection on 5 and 18 May 2021. Inspectors looked only at Safe and Well-led after concerns about medicines, meals, staffing, the environment and care. They spoke with people, relatives and staff, reviewed medicines and care records, and checked the building and equipment.
The home was rated Requires Improvement overall, Safe and Well-led. Inspectors found medicines records and temperature checks were not always complete. Some risk equipment was set incorrectly, and records did not always show the support people received. Audits had not picked up these problems. There was also no registered manager at the time.
People said they felt safe and liked the staff. Staff were kind, knew people's needs and were available during the inspection. The provider acted quickly during the inspection by changing checks, correcting equipment settings and improving records. These changes needed to become established, and CQC said it would monitor the home and return as part of its reinspection programme.
Kind staff
Inspectors saw staff being patient and respectful. People said they liked the staff.
“Staff were kind and respectful with people and were patient when they supported them. People told us they liked the staff.” from the report
Staff availability
Staff responded promptly during the inspection and said they had no concerns about staffing levels.
“Staff responded to people promptly during the inspection and staff had no concerns about the availability of staff to support people.” from the report
Personalised medicines support
Although medicines management had problems, staff gave medicines in a way that reflected people's preferences.
“Staff administered medicines in person centred way, spending time with people and meeting their personal preferences as to how and when their medicines were administered.” from the report
Action during inspection
The provider responded quickly to concerns by changing processes, checking equipment settings and improving care records.
“The provider and acting manager took swift action during the inspection process to reduce risks and improve the service.” from the report
Medicines checks
seriousA medicines administration record did not match the amount of medicine remaining. Medicine room and fridge temperatures were not always recorded.
“A medication and administration record did not match with the actual amount of medicine remaining and daily medication room and fridge temperature checks were not always carried out.” from the report
Risk and care records
seriousSome equipment was set significantly higher than people's documented weights. Records did not always show repositioning support or help with behaviours that may challenge.
“This posed a risk of people receiving care that did not meet their needs.” from the report
Weak audit system
needs fixingInternal checks had not identified the medicines, equipment and care-record problems. New checks had been introduced but still needed to become established.
“Audits and checks had not consistently identified shortfalls and driven improvement.” from the report
Management communication
needs fixingThere had been management changes and no registered manager. Relatives said they could not always speak to management and were not always told about changes.
“Relatives commented they felt collaborative working between themselves and the service could be improved.” from the report
Infection control lapse
needs fixingOne member of ancillary staff was seen without a mask while walking through the dining room when people were present. The managers acted after inspectors raised this.
“We observed a member of ancillary staff did not wear a mask when walking through the dining room and people were present.” from the report
- 01How are medicines records, stock levels and medicine-room and fridge temperatures now checked every day?
- 02How do you check that equipment settings match each person's current weight and care needs?
- 03How do you make sure repositioning and other care are recorded consistently?
- 04Who is currently responsible for the home while the manager's registration is being processed?
- 05How will relatives be told about management changes and how can they speak to a manager?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings carried over into the overall rating. This explanation was written from the published report of 7 July 2021 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 Swillbrook House Residential Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Swillbrook House Residential Home →
- July 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Swillbrook House Residential Home →
- February 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015
Registered with the Care Quality Commission on 21 December 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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