Archived: Swanrise

Updated 6 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 3 inspectors (one of whom specialised in medicines) and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Swanrise is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Swanrise is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We reviewed support plans and associated records for 4 people. We reviewed medicine administration and associated records for 6 people and spoke with 2 members of staff about medicines. We spoke to 2 people who lived at the service briefly and observed staff delivering care to 3 people. We spoke with the deputy manager and operations manager.

After the inspection we received further documentation electronically, such as governance audits, recruitment files, supervisions and minutes of meetings. We spoke with 5 relatives, 3 support workers and one learning disability nurse. We continued to liaise with the local authority about our concerns following the inspection.

Updated 6 October 2023

About the service

Swanrise is a residential care home providing personal care to up to 6 people. The service provides support to adults with learning disabilities, autism and mental healthcare needs. At the time of our inspection there were 6 people using the service.

The layout of the building did not provide an environment where people had freedom of movement. This meant that some people were restricted to certain areas of the service, and we observed that most of the day, that is where they remained. This also impacted in some cases on people’s privacy and dignity.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

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

We found the service was not able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture and best practice guidance. This meant people were at risk of not receiving the care and support that promoted their wellbeing and protected them from harm.

Right Support: Model of Care and setting that maximises people’s choice, control and independence.

Care was not always provided in a dignified manner and people's human rights were compromised. People were subject to restrictive practices without proper regard to legal processes and requirements. 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.

The provider had failed to mitigate the risks in relation to the internal and external environment. They had not done all that was reasonably practicable to reduce the risk and provide care in a safe way. This resulted in service users being placed at risk of harm and coming to actual harm. Infection prevention and control measures were not robust and some areas of the service were visibly dirty and unhygienic.

Right care: Care is person-centred and promotes people's dignity, privacy and human rights

Care was not provided in a person-centred way which promoted people's dignity, independence or human rights. There were not always staff with suitable skills deployed to meet the needs of people; there were identified gaps in staff training and we were not assured staff had the skills and knowledge to fill the requirements of their role. We found medicines were not always safely managed and medicine records were not always completed accurately. People's dietary and health needs were not well documented which meant we could not be assured that people had access to regular health checks, or that a healthy and balanced diet was being offered to people.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

The service lacked leadership and risk management. The provider's systems for monitoring and improving the quality of the service had not been effective, because people were not always receiving a good quality of service and some risks had not been mitigated. This placed people at continued risk of harm.

The systemic failings outlined in this report demonstrated the provider had failed to ensure people received a well-managed service which was safe and compassionate placing people at risk of potential harm.

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 16 December 2019).

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 the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to the poor quality of care people were receiving. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

The overall rating for the service has changed from Requires Improvement to Inadequate based on the findings of this inspection.

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 Swanrise on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people, staffing, risk management, medicines, nutrition and hydration, and governance at this inspection. Due to the significant concerns we found, after the inspection we continued to work closely with the local authority and safeguarding teams.

We issued a Notice of Proposal to vary the conditions of the providers registration so they were no longer authorised to carry on providing services at Swanrise. We received no representations from the provider, so we issued a Notice of Decision. This means the service is no longer in operation.

Follow up

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.