CQC report explained · a residential care home
What the CQC found at The Swallows Residential Care 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, March 2023
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, staffing, medicines and management.
This was an unannounced focused inspection on 9 and 16 January 2023. Inspectors looked at Safe, Effective and Well-led. They spoke with people living in the home, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was not always safe. Inspectors found risks from poor infection control, unsafe or damaged areas, fire safety, unlocked external doors, medicines records and unclear care plans. They also found that staffing levels were not always enough and recruitment checks were incomplete.
The home was rated Requires Improvement for Effective and Inadequate for Safe and Well-led. The overall rating changed from Requires Improvement at the previous inspection to Inadequate. The home was placed in special measures because people were at risk and the provider's systems had not found or dealt with important problems.
Visitors allowed
People could receive visitors without restrictions during the inspection.
“People were able to receive visitors without any restrictions as the provider and staff team were following government guidance.” from the report
Personalised bedrooms
Inspectors found that people's bedrooms were homely and included personal belongings.
“People's internal bedrooms were personalised, homely and included lots of their personal possessions.” from the report
Some positive staff feedback
Most staff said they felt supported and enjoyed their work at the home.
“The majority of staff told us they felt well supported and enjoyed their job role working at The Swallows Residential Care Home.” from the report
Some relatives were positive about medicines
One relative said they believed staff made sure their family member took their tablets.
“As far as we are aware, they [care staff] are very good and they make sure [family member] has taken their tablets.” from the report
Infection control and building condition
seriousInspectors found mould, rusty equipment, damaged flooring and poor cleaning conditions. These problems increased the risk of infection spreading.
“We found extensive black mould on the ceiling and walls in the laundry room.” from the report
Fire and environmental safety
seriousFire alarm checks had not been recorded since September 2022. A fire door did not close fully and a fire exit was partly blocked.
“During our inspection, we also found a fire door did not close fully and a folded wheelchair and floral display partially blocked a fire exit.” from the report
Medicines records
seriousSome medicines records were incomplete or altered unsafely. Creams were used without opening dates or past their expiry dates, and stock did not always match the records.
“We found staff had used correction fluid on MAR charts to make alterations or amend previous entries.” from the report
Not enough staff at some times
seriousThere were two staff on duty after 5pm, although five people needed two staff for their care. Staff also had to take on cooking and domestic duties after those workers left.
“During this inspection we found that the staffing increase had not been sustained, and there were only 2 staff on shift after 5pm.” from the report
Incomplete training and recruitment checks
seriousSome staff had not completed important training, including safeguarding and first aid. Recruitment records did not always show full employment histories or suitable references.
“The provider had failed to ensure there were sufficient numbers of suitably trained staff deployed in the service.” from the report
Poor management oversight
seriousAudits and checks failed to identify or address the problems inspectors found. Care plans were not always accurate or up to date, and accident reviews did not identify ways to prevent repeat incidents.
“The quality assurance systems were not robust.” from the report
- 01How many care staff are now on duty after 5pm, and how do you assess staffing levels against each person's needs?
- 02What has been done to fix the mould, damaged flooring, rusty equipment, fire door and blocked fire exit?
- 03How are medicines now checked, including handwritten records, refused doses, cream expiry dates and stock levels?
- 04Have all staff completed safeguarding, first aid, fire safety and other training relevant to people's needs?
- 05What changes have been made to care plans, mental capacity decisions, DoLS records and healthcare referrals?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward when calculating the overall rating. This explanation was written from the published report of 11 March 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, July 2021
Rated Requires Improvement; inspectors found kind care and safe medicines, but infection control and management systems were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 16 March 2021 and completed the inspection on 9 May 2021. They spoke with staff and relatives, observed care, and checked records, staffing information and recruitment checks.
The home had enough staff for many people’s needs, and staff were described as caring and available. Medicines were given as prescribed. However, staff did not always follow COVID-19 infection control guidance. There were also times when there was no extra staff member to supervise communal areas.
Inspectors found that some dementia-related risks were not properly recorded. They were also not assured that the provider’s checks and audits found problems or led to effective improvement. Safe and well-led were rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
Medicines
Medicines were recorded as being given as prescribed, with guidance available for medicines needing specific administration.
“Medicines administration records showed that medicines were given as prescribed and there was information about how to administer medicines that needed to be given in a specific way.” from the report
Staff availability
Inspectors saw staff respond quickly to call bells and provide care without appearing rushed.
“Staff worked in an unhurried way and were available for people.” from the report
Safeguarding
Staff understood how to report possible abuse, and the provider had safeguarding systems in place.
“The provider had effective safeguarding systems in place.” from the report
Caring staff
Staff told inspectors they were committed to providing care and supporting one another.
“All of the staff we spoke with said that people were well cared for.” from the report
Infection control
seriousStaff did not consistently follow COVID-19 guidance. Inspectors found problems with masks, reusable visors, PPE disposal, staff breaks, window visits and cleaning records.
“Staff did not follow government guidance on COVID-19 closely enough keeping people safe from the possible transmission of infection.” from the report
Staffing in communal areas
needs fixingThere were times, especially in the evening, when only two care staff were on duty and no extra staff were available to supervise communal areas.
“The needs of people using communal areas meant they were at risk if staff were not easily available.” from the report
Dementia risk records
needs fixingA person’s records recognised dementia but did not set out their specific risks or record how staff responded to distress and calling out.
“Although this person's risk assessments indicated they lived with dementia, there was no additional information to identify specific risks in relation to this.” from the report
Quality checks
needs fixingThe provider had audits and monitoring systems, but inspectors were not assured that these checks identified all concerns or were robust enough to ensure infection guidance was followed.
“We were therefore not assured that the provider's process for monitoring infection control practice was robust enough to ensure guidance was followed properly.” from the report
- 01What changes have you made to ensure staff follow current infection control guidance, including masks, visors, PPE disposal and cleaning of frequently touched surfaces?
- 02How many care staff are now on duty in the evening, and who supervises communal areas when care staff are helping people elsewhere?
- 03How are dementia-related risks recorded in each person’s care plan, including calling out, distress and the support that works for them?
- 04What checks do managers now complete to make sure infection control and staffing improvements are working?
- 05How can relatives give feedback or request a care review while formal surveys are not being carried out?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 9 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 The Swallows Residential Care Home
4 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- March 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
Read what inspectors found at The Swallows Residential Care Home →
- July 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Swallows Residential Care Home →
- May 2018Goodstayed GoodSafe: Requires improvementEffective: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Registered with the Care Quality Commission on 17 June 2013.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
23 live-in carers within about an hour of Suffolk
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 £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
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.