The Care Quality Commission (CQC) has rated Swan House care home in Willenhall, Walsall, inadequate and placed it into special measures to protect people, following an inspection in November.
Swan House, run by Absolute Healthcare Swan House Limited, is a care home which provides personal care for up to 45 people, including some living with dementia. At the time of this inspection 40 people were living at the home.
This focused inspection was carried out to follow up on action CQC told the provider to take following the previous inspection in August after which they were issued with a warning notice to make specific improvements including; medicines management, staff training and the monitoring of the quality and safety of care.
Following this latest inspection, the home’s overall rating has dropped from requires improvement to inadequate, as have the ratings for being safe, effective and well-led. As this was a focused inspection, caring and responsive weren’t included and therefore remain rated requires improvement.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and it will be monitored to check sufficient improvements have been made.
Andy Brand, CQC deputy director of operations in the midlands, said:
“When we visited Swan House, it was disappointing to find they hadn’t made the improvements we told them to make in our warning notice to them after their last inspection in August.
“At this latest inspection, we found the home wasn’t well managed, there wasn’t strong leadership, and there was a lack of understanding from staff about their roles, which placed people at risk of harm.
“Our inspectors found care plans and risk assessments didn’t have enough detail and weren’t always being followed. We saw this lack of detail put people at risk on multiple occasions. For example, we saw someone whose care plan said they needed supervision and a zimmer frame moving around the home independently putting them at risk of falls. Another person was at risk of choking, which had happened in the past. Their care plan said they needed their food cut up, which hadn’t been followed by staff and which meant they were eating uncut food, putting them at risk of choking again.
“Also, there was no detailed guidance for staff on how to support people when they became emotionally distressed. There were times when this resulted in people assaulting other people living in the home. This is unacceptable and put people at significant risk of harm.
“We have told Swan House where we expect to see rapid, widespread improvements and will continue to monitor them closely to keep people safe during this time. We will return to check on their progress and won’t hesitate to take further action if people aren’t receiving the care they have a right to expect.”
Inspectors found:
- People using the service and their relatives raised concerns around staffing levels as there weren’t enough staff to help with people’s every day personal care. In some cases, relatives came in at lunchtime to support their loved ones to eat, as they felt they wouldn’t get the support they needed if they didn’t
- Staff had not received training to support people who had dementia and displayed periods of emotional distress
- People did not always receive pain relief when needed and medicines were not always safely managed, as stock checks were inaccurate, and bottles opened were not dated
- There were not enough suitably recruited staff to support people
- People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice
- Safeguarding procedures were in place and followed to report concerns but there was a lack of accountability in the home with regards to this
- The systems in place to monitor the home, the care people received were not effective as they had failed to identify concerns
- People did not have access to call bells when in their room so were unable to access support when needed.
However:
- The home was clean on the day of the inspection
- Signage had been used to support people living with dementia.
The report will be published on CQC’s website in the next few days.