Swan House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The provider had developed a clear mission statement and vision which staff used to deliver compassionate care to people. Staff were complimentary about the change in management structure and said they felt able to speak to the registered manager and seek support. Staff told us they engaged in learning through the provider’s governance procedures which were effective in monitoring quality and driving change. Partners told us the provider had developed good relationships with them and had worked in partnership to deliver improvements. Staff were supported in an inclusive environment and the registered manager used systems to learn and make continuous improvements.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff described an improved culture at the home and they were aware of the values and mission of the service to provide a caring safe environment for people. Staff were positive about the changes which had been put in place. One staff member told us, "100% the service has improved since the registered manager and deputy came here. Until they came we did not have any support. It has got so much better, morale has gone up and its lovely now." The registered manager described how they were following an action plan to make changes to the culture of the home. The vision for the service promoted a culture empowered the team to work together and that team work was essential to ensure good outcomes were achieved for residents and to ensure people had a good quality of life.

The provider had a mission statement and values which had been compiled with people, relatives and staff. This was widely understood and staff displayed the values in the care they gave to people.

The nominated individual described the registered manager induction process. They explained this had changed following a lesson’s learned exercise and they now had a full process with competency assessments and regular supervisions which included reflective practice. Staff reported they had confidence in the capability of the leadership team. One staff member told us, "In staff meetings, we can speak to the management team and at any time about things, we give feedback and receive feedback on what we are doing, this helps us to know what's expected."

The leadership team had promoted a new culture and had changed practices to support this. For example, they had changed how recruitment was conducted, introduced reflective practice and had focused on staff wellbeing.

Staff described feeling able to report concerns to the provider and they were confident action would be taken. One staff member told us, "Things have really improved. Staff didn't used to report things because they were scared of being told off. Now we're being supported, they are teaching us, we know what's expected of us, the management team have high standards and we know that. I can talk to them anytime, they are here working with us." The registered manager described the policies in place to support staff to have the freedom to speak up. They told us about the whistleblowing policy and that staff were encouraged to speak up, including speaking to CQC if they felt it was required.

The provider operated an open door policy. The whistleblowing policy protected staff who spoke up about concerns.

Staff gave examples of how the registered manager had provided individual support and adjustment to enable staff members to carry out their roles. The registered manager described how they had developed a culture which supported staff within the context of protected characteristics. They reported they had a diverse staff group and embraced individual cultures through activities at the home. They confirmed all staff had received Diversity and Equality training and their aim was to reduce inequality.

The provider had systems in place to ensure they supported staff with their diverse needs. Training and development was in place to ensure staff understood diversity and how to reduce inequalities.

Staff reported how checks were now in place to ensure people were getting the care they needed. One staff member told us, "Before nobody ever checked what we did, so some people didn't do it, or do it right. Now someone is checking and feeding back so staff can learn." The registered manager described a range of systems they used to check the quality of the care people received. For example, there were regular meetings to discuss risks to people’s safety, a resident of the day process to check on care plans, regular daily checks on staff recording and checks on clinical risks such as tissue viability.

Effective processes monitored the quality of the care people received. Where audits identified issues, action had been taken to address these. For example, the care plan audit identified a need to update DNACPR records and this was completed. A medicines audit identified issues with stock control and systems were changed to prevent this from happening again.

People and their relatives described effective partnership working. One relative told us, "I am kept up to date at all times, I always worry when they call me, but so far it has not been bad news’ ‘the manager is very good, her door is always open."

The registered manager and staff described how they had developed good partnership relationships with a range of local agencies. They described how they worked closely with local commissioners to help shape and develop the service. People, relatives and staff were also viewed as partners and engaged in the services development.

Partner agencies reported that the changed leadership team had worked hard to improve the quality at the home and had worked in partnership with local agencies using a multidisciplinary approach. Partners told us the provider was open and transparent.

The provider had promoted a culture that encouraged effective partnership working. This had resulted in effective partnership working that had significantly improve the safety and quality of the care provided.

Staff described a learning and improvement culture. One staff member told us, "Yes, we learn from what goes wrong, and the managers are teaching us as well. I can talk to either of them." The registered manager described the systems used to ensure staff had the opportunity to learn when things went wrong. They shared information with staff about developments and improvements to the service through a range of opportunities including meetings and workshops, aiming to increase staff skills and knowledge.

Effective processes had been embedded to learn and improve the service. For example, action plans were in place to deliver changes following audits, these included what was needed who should complete them and by when. All improvements were logged in an audit tracker which helped the registered manager to ensure improvements were made as planned.