Swan Court

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

At our last inspection we found the service was not effectively managed and good governance was not established. During this assessment we found not enough improvements had been made, and this was a continued breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff feedback showed understanding of the responsibilities and accountabilities of their roles. The provider told us the introduction of an electronic quality management system had enhanced their oversight and we saw a service action plan was in place. Staff described a supportive working environment and the provider sought staff and people’s feedback through surveys.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff described a supportive, inclusive working environment, with good team work, effective communication, and accessible management support. There was a new manager who intended to apply to CQC as the registered manager. Comments from staff included, “We are a small team, get on with each other, feel like we can talk to each other or approach [care coordinator] if we need to” and “I love working here…if raise something gets dealt with, feel [care coordinator] good at her job.” Staff feedback showed understanding of the responsibilities and accountabilities of their roles. Staff understood the importance of confidentiality. Leaders shared feedback about actions taken following an annual staff survey. This included improving staff spaces to create more relaxing spaces for staff to take breaks. Staff also highlighted the provider’s website updated staff, such as feedback from staff surveys.

We found audit systems were not fully effective, because they had not identified some of the concerns we found and the provider did not follow their own quality assurance policy. Additionally, the provider's medicine audit had not identified the issues we found with medicine records. Records relating to medicines were not always complete. “As required” pain relief when administered was not recorded as given in line with the provider's policy. Other medicine records such as relating to the administration of fluid thickener was not routinely recorded as administered and the medicine stock discrepancy records did not assure us that stock discrepancies were appropriately investigated.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.