Swan House

Swan House is a residential care home providing accommodation and personal care to 10 people aged 65 and over, at the time of the inspection. The service can support up to 32 people.

Swan House accommodates up to 32 people across two units, each of which have a small kitchen area, dining room, sitting room and communal bathrooms. The bedrooms have en-suite shower facilities. One of the units provides care to people living with dementia.

People’s experience of using this service and what we found

We found safe care and treatment was provided. People were safeguarded from risks of abuse and other risks. Safe medicines practice was followed, and people told us they received safe care. Accidents and incidents relating to people using the service were monitored to identify wider learning for the service.

People were protected from infection control risks in relation to COVID-19, although we observed some instances of poor practice. The service was responsive to our feedback. People told us staff wore personal protective equipment (PPE) to support them, and people’s mental capacity had been considered in relation to regular testing for COVID-19. Relatives were able to book appointments to visit. One relative commented, “They have a separate entrance and [we go] upstairs to a room that is cleaned every time…they are very particular about cleanliness…we can phone on video calls anytime.”

People told us they received safe care. Some people living with dementia were not able to tell us about their experiences of care. We observed communal areas at different times of day, including at meal times and during activities. Staff spoke warmly with people, offering choices of food and drink, and supporting people to engage in activities such as bingo. People appeared relaxed in the company of staff. Some people preferred to spend more time in their rooms. We observed rooms were personalised and one person using the service was supported to keep their cat with them.

Safe recruitment procedures were in place. People were supported by sufficient staff, including support from senior staff on each shift. A structured handover process was in place, to ensure incoming staff were aware of any current concerns or changes for the people they support. Staff told us they had access to training and regular supervision, however we found staff had not completed a yearly appraisal at the time of our inspection. We found the provider's policy required staff to complete moving and handling training on a three yearly basis, which was not in line with best practice guidance. We recommended the provider refer to best practice guidance in relation to the training topics, training frequencies and assessing staff competencies to review their approach.

The management of the service had improved, however there had been a significant delay in recruiting a new home manager since our last inspection. An interim manager had worked to support the service to make improvements, and the provider conducted audits and regular quality meetings to review progress. A full-time manager joined the service in August 2021 and we received positive feedback from people, staff and relatives. The manager had made a positive impression and was viewed as accessible and supportive by the staff team.

Feedback from relatives also confirmed improvements had taken place. Comments from relatives included, “General feeling that staff are more confident about what they are doing”, “Communication now is much better”, “Staff are helpful and responsive to emails; things have changed and improved since new management”, “I think it will go from strength to strength…I am very happy" and “Honestly we are happy and there is nothing I would change. They don’t have a high turnover of staff so there is continuity and that’s important."

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however the policies and systems in the service did not always support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was inadequate (published 12 January 2021).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found some improvements had been made, however the provider was still in breach of regulations.

This service has been in Special Measures since January 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 25 November 2020. Breaches of legal requirements were found in relation to safe care and treatment, safeguarding from abuse, recruitment practices, consent to care, good governance, duty of candour and in informing the Commission of incidents they are required to. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Swan House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to consent to care and duty of candour.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Swan House is a residential care home providing accommodation and personal care to 16 people aged 65 and over, at the time of the inspection. The service can support up to 32 people.

Swan House accommodates 32 people across two units, each of which have a small kitchen area, dining room, sitting room and communal bathrooms. The bedrooms have en-suite shower facilities. One of the units provides care to people living with dementia.

People’s experience of using this service and what we found

We had limited feedback from people about their care. We observed some people had positive relationships with staff and they were relaxed and happy in staff company. Some people told us they wanted to be at home and others gave us mixed feedback on the meals and activities provided. A person commented, “The activities available don’t interest me” and “The food varies, the meatballs today were better than I have had before.”

A relative told us they were extremely happy with their family member's care. They felt confident that their family member was safe and well cared for. They commented "[Family member's name ] is happy, safe and comfortable. I feel the staff fully understand their needs and can calm and reassure them."

A health professional commented "I have always found the staff at Swan house to be caring, willing to go the extra mile and proactive, in the course of my involvement with the home."

We found safe care and treatment was not provided. People were not safeguarded from abuse and risks to them, including infection control risks which were not identified and managed. Safe medicine practices were not promoted. Accident and incidents were not effectivley managed and there was no evidence of learning from these incidents to prevent reoccurrence.

Safe recruitment practices were not followed, and staff were not always supervised and trained in line with the provider’s policy.

The records and systems in the service did not support best practice on the application of the Mental Capacity Act 2005 to ensure people were supported to have maximum choice and control of their lives in the least restrictive way possible and in their best interests.

The service was not effectively managed and monitored. The registered manager did not oversee the delegation of tasks and where actions were agreed they were not followed up and addressed. They failed to make the required improvements to the service and had not identified where other improvements were required. Staff felt well supported by the senior care team but less so by the management of the service.

The registered manager failed to make the required notifications to us and did not understand their responsibility under the duty of candour regulation. Some records relating to the running of the service were unavailable, contradictory, incomplete and not suitably maintained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update The last rating for this service was requires improvement (published 12 December 2019) and there were multiple breaches of regulations. The service has been rated requires improvement for the past three consecutive inspections. At this inspection the rating has deteriorated further.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was in continued breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

We inspected and found there was concern with the management of risks, medicine practices, safeguarding people, consent to care, recruitment of staff, records and good governance so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Swan House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified continued breaches and new breaches of regulations at this inspection in relation to safe care and treatment, safeguarding from abuse, recruitment practices, consent to care, good governance, duty of candour and in informing the Commission of incidents they are required to.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Swan house is a care home providing residential care for up to 32 older people living with dementia and people with sensory and or physical disabilities. Care is provided over two floors, one specialises in providing care to people living with dementia.

People’s experience of using this service and what we found

People told us they felt safe living in the service. Comments included “Yes I feel very safe, if I need help I have an alarm I can pull.”

We had several concerns about the safety of the service, this included the unsafe administration of medicines by a staff member, who failed to use protective equipment and placed tablets into a person’s mouth using their fingers. Liquid medicines were disposed of down the plug hole of the kitchen sink, and medicines had gone missing from the service.

People were not always supervised sufficiently to keep them safe. The conduct of one staff member did not convince us of their ability to provide care safely or appropriately.

Safeguarding concerns were not responded to appropriately and failed to be notified to the local authority or to the Care Quality Commission (CQC). This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

Recruitment practices needed improving to check records of candidate’s previous employment histories were correct and to identify the reasons for any gaps.

We observed poor practice in relation to the care provided to a person eating their lunch. People’s care as documented in their care plan was not always followed through into practice. Care was not always person centred.

Staff received an induction and training to provide them with sufficient skills and knowledge to do the job. We have made a recommendation about the support on offer to staff.

People had access to health professionals to ensure they maintained their health. Where advice was given this was documented.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We observed a staff member breach confidentiality by discussing other people’s issues openly. People were not always referred to by their preferred title and not always shown respect by staff.

People were supported to be involved in activities to protect them from social isolation. When people needed assistance with communication, staff were aware of how to do this.

People’s last wishes were discussed and recorded to ensure their preferences were respected. An end of life care plan was put into place when the person reached the final stage of life.

We found the service had not been well led. Although improvements had been made in some areas we found several concerns. The registered manager and senior staff had not identified the areas for improvement we found. Information that was required to be shared with other organisations hadn’t been shared. There did not appear to have been a thorough management overview of the service.

The registered manager and provider had not fulfilled their legal responsibilities, for example notifications had not been sent to CQC. Performance management of staff hadn’t been undertaken when needed. Policies were not up to date and accurate.

Improvement has been made to the staff understanding of the duty of candour legislation since our last inspection.

There were strong positive links with the local community which people from the service benefitted from. Visits by local guides and scouts helped to improve the garden environment.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 7 August 2018).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Swan House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to Regulation 18 (Notification of Other Incidents) of the Care Quality Commission (Registration) Regulations 2009. Regulation 10 (Dignity and Respect); Regulation 12, (Safe Care and Treatment); Regulation 13 (Safeguarding service users from abuse and improper treatment); and Regulation 17 (Good Governance) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. at this inspection.

We have issued a warning notice for the breach of Regulation 12 (Safe Care and Treatment). We require the service to have made sufficient improvements to be compliant with this regulation by the 1 December 2019.

Follow up

We will meet with the provider after this report is published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

assurance system in place to effectively monitor the safety and quality of people's care.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and well led to at least good.

During this inspection we found there were sufficient numbers of staff to meet people’s needs, however, we still had concerns about the quality assurance systems in place to monitor the service.

Swan House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Swan House accommodates up to 32 older people. The home is split over two floors, each with16 places. All rooms have en-suite accommodation. The downstairs accommodation is provided for people who live with dementia. The first floor provides residential care. At the time of our inspection there were 28 people living in the service. The service is managed by a registered manager.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found some concerns with the safety of the service these included lack of precautions to prevent the contamination of food and the spread of infection. These included, packaging of food, which was not sealed, food containers left open, no use by dates on decanted food stuff and a lack of protective equipment when handling food. This meant poor hygiene standards in small parts of the kitchen placed people at risk of infection.

We also found the external environment placed people at risk of falls due to uneven paving. In addition a lack of sun shade meant people would be exposed to the sun and at risk of sun burn. Duck excrement in the graden meant the risk of infection spread by flies was increased.

Medicines were administered safely by trained staff. Improvements to the recording of medicines stock were to be implemented to ensure potential errors could be easily identified..

Staff received support through supervision, appraisals, training and staff meetings. Staff told us they received adequate training to fulfil their role.

The service was compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the service had policies and procedures in place to support this practice.

People’s dietary and health needs were taken into consideration and where appropriate, external professionals were contacted to provide support to staff and people. Care plans reflected advice given.

Staff were caring and people appreciated their support. Healthy relationships had been forged with staff who treated people with respect and protected their dignity. People appeared well cared for and their preferences in relation to the support they received was clearly recorded.

The service was complying with The Accessible Information Standard. Where people had communication or sensory difficulties the service sought ways for them to access information in a way that was suitable for them.

The service treated people equally regardless of their gender or lifestyle. People were viewed as individuals with individual needs.

People were protected from the risk of social isolation as many in house and community activities were on offer to them to participate in.

The complaints procedure was accessible to people. Where people had concerns senior staff were available to discuss these. Records showed the registered manager took complaints seriously and acted quickly to improve the situation for people.

Although the service had increased the number of audits since the last inspection in December 2016 we found some areas hadn’t been identified as requiring improvements. For example, the kitchen. As a result, the service was found to be lacking in some areas. If the quality assurance systems were not effective enough to both recognise and address the areas of concern, we could not be assured the service was safe.

People and staff spoke positively about the registered manager and the senior staff. Innovative ideas had been put into practice within the service to improve the health and wellbeing of people living there.

The provider did not have a duty of candour policy in place and staff had not received training. We have made a recommendation about this.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Swan House provides accommodation and care for up to 32 older people. The home is split over two floors, each with16 places. All rooms have en-suite accommodation. At the time of the inspection there were 25 people living at the home. The home does not provide nursing care.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection the registered manager was unavailable. We therefore spoke with one of the deputy managers and the Head of Buckinghamshire Services for Heritage Care.

At the last inspection on 23 April 2014 the provider was in breach of Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010. Assessing and monitoring the quality of service provisions. This is equivalent to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We asked the provider to make improvements to how they recorded audits in the home and any subsequent actions.

The provider sent us an action plan outlining the actions they were going to take. At this inspection we found improvements had been made and the provider had completed these actions.

People and staff told us there were not always enough staff on duty to meet people’s needs. People gave us examples of how they had been kept waiting for care and staff told us sometimes they struggled to meet people’s needs due to lack of staff.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role.

People and their families told us they felt safe at Swan House. Staff understood their responsibilities in relation to safeguarding people. Staff received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the authorities where concerns were identified. There were robust management systems in place of people’s medicines and people received their medicine as prescribed.

Some people benefitted from caring relationships with the staff. Other people told us they felt at times staff were not always caring toward them. People and their relatives were involved in their care and people’s independence was actively promoted. Relatives and staff told us people’s dignity was promoted.

Where risks to people had been identified, risk assessments were in place and action had been taken to manage these risks. However, people’s care plans had not always been updated with any changes of risks to people. Staff sought people’s consent and involved them in their care where possible.

People and their families told us people had enough to eat and drink. People were given a choice of meals but their preferences had not always been respected. This was because proposed changes to the lunch time food had not been implemented. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

Professionals and people told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided, but these were not always robust as they had not identified areas of concern at the inspection. Learning needs were identified and action taken to make improvements which promoted people’s safety and quality of life. Systems were mainly in place that ensured people were protected against the risks of unsafe or inappropriate care.

Staff spoke positively about the support they received from the Registered Manager and all of the team at the home. Staff supervisions were scheduled. People, their relatives and staff told us all of the management team were approachable and there was a good level of communication within the service.

People and relatives told us the service was very friendly, responsive and very well managed. The service sought people’s views and opinions and acted on them.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

People were cared for in an environment that was safe and protected them against the risk of harm. One person told us 'I feel very safe here.' We saw the environment of the service was well maintained and ensured people's safety and welfare. Safeguarding posters were available throughout the home to ensure staff, people who used the service and relatives knew who to contact if they had concerns about peoples safety and wellbeing.

Is the service effective?

People's care plans reflected their care and treatment needs and corresponded with what staff told us about their care needs. Medication was administered in a way that was intended to ensure people's safety. Where errors had been made, the provider had a system in place to ensure staff were retrained to ensure people's welfare. People could be sure they were supported by staff who were suitably qualified and vetted to undertake their roles.

Is the service caring?

We saw positive interactions between staff and people who used the service. We saw an example of one person who was not eating their lunch and they were offered a suitable alternative at their request. We saw one staff member reading and discussing a magazine with a person using the service. One person told us 'The staff are all very kind.' We saw one person was supported to access the local community at their request.

Is the service responsive?

We saw the service was responsive to people's needs. Where issues were addressed such as dietary needs or people were assessed at risk of weight loss, this was managed appropriately and other professional input was obtained as required.

Is the service well led?

We saw regular audits where undertaken within the service, however this was not always clear who was responsible for actioning any issues that arose or a timescale for when this would be done. Reviews and keyworker meetings were undertaken with people who use the service however we found no evidence of these meetings being undertaken. The provider had a system in place to identify issues however this were not always evidenced as being acted upon to ensure the quality of the service provision.

Support for staff had improved. The service had a programme of supervision, meetings and appraisal. We saw team meetings had taken place, supervision was being established and there were plans to appraise all staff by the end of June 2013.

Procedures for monitoring the quality of the service included risk assessments, monitoring of complaints and incidents, reports to senior managers, audit of activities, and an annual survey. A monthly summary of accidents and incidents had been introduced to identify patterns of such events and indicate where action to reduce the risk of such an occurrence was required. The service had been inspected by an environmental health officer (EHO) in January 2013 and been awarded five stars for standards of food safety. We found records relating to people's care, complaints, accidents, and health and safety were accessible and in good order.