Swanland House

Swanland House is a privately owned residential care home that operates in a Grade 11 listed building.

The leadership, governance and culture did not promote the delivery of high-quality person-centred care. Managers did not lead effectively, and staff did not feel listened to or valued.

The provider did not provide consistent leadership and managers were not clear what their roles and responsibilities were. Staff told us, "[Registered manager] was supportive but was a 'jack of all trades' and did everything."

The registered manager did not regularly review staffing levels and adapt them to people's changing needs to ensure there were enough competent staff on duty. Relatives told us, "I don't think there are enough staff" and "The home has been dreadfully short staffed." Recruitment systems were robust and ensured the right staff were recruited to support people to stay safe.

There is limited use of systems to record, manage and report concerns about risks, safety and incidents. People were not involved in managing risk. Risk assessments were not person centred and reviewed regularly. People did not always receive their medicines as prescribed. Medicines were not stored correctly and disposed of safely.

The providers quality assurance arrangements were not strong so did not identify current and potential concerns and areas for improvement. Concerns were not investigated, and there were no opportunities for learning when things went wrong.

Staff supervision and support was inconsistent. Training and development plans were not designed around learning needs and the care and support needs of people who use the service. We have made a recommendation about supervision and appraisals.

The service monitored people's heath, care and support needs, but did not consistently act on the issues identified. There was a process in place for referring people to external services.

Staff had an awareness and understanding of abuse and knew what to do to ensure people were protected.

The service manages the control and prevention of infection well. Staff are trained and understand their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises.

People had access to suitable outside space, a quiet area to see their visitors, an area suitable for activities and private areas where people could be alone.