Peridot View
Walsall, WS3 · 1.4 km
Residential
Not yet ratedcare home
CQC report explained · a nursing home, run by Absolute Healthcare Swan House
Swan House
Pooles Lane, Short Heath, Willenhall, WV12 5HJ
Goodpublished 24 July 2024, 2 years ago
Rated Good: inspectors found the service performing well and meeting their expectations.
The latest report, explained
What inspectors found, May 2024
Rated Inadequate and placed in special measures; inspectors found people at risk from unsafe care, poor staffing and weak leadership.
This was an unannounced focused inspection on 22 November 2023. Inspectors reviewed information received about the home, spoke with people, relatives and staff, checked 18 care records and examined staffing, medicines and management records.
Inspectors found serious problems with safety. Risks were not regularly reviewed, care plans were missing or not followed, falls equipment did not always work, call bells were not always within reach and people did not always receive pain relief. Medicines records and stock checks were also unreliable.
There were not enough staff, and some staff lacked the training and knowledge needed to support people safely. People were also at risk from poor support with food, specialist diets and weight loss. Mental capacity and best-interest decisions were not properly recorded.
The overall rating changed from Requires Improvement to Inadequate. The safe, effective and well-led areas were all rated Inadequate. Caring and Responsive were not assessed during this focused inspection.
What inspectors praised
Clean environment
The home appeared clean on the inspection day. Staff were also seen wearing protective equipment when needed.
“The home was clean on the day of our inspection.” from the report
Dementia-friendly signs
Some signs had been added to help people living with dementia find their way around the home.
“Since the last inspection some signs had been put in place to support people living with dementia.” from the report
Recruitment checks improved
The provider had improved some recruitment checks, including references and police checks. However, inspectors still found gaps in two people's records.
“The provider had taken action to ensure checks were in place for staff working at the home including references and police checks.” from the report
What inspectors were concerned about
People were at risk of harm
seriousRisk assessments and care plans were missing, incomplete or not followed. Incidents, including assaults and falls, did not always lead to effective action to keep people safe.
“This placed people at risk of significant harm.” from the report
Unsafe medicines management
seriousSome liquid medicines were not dated when opened, stock checks were inaccurate and one person was not given requested pain relief.
“People did not receive pain relief when needed.” from the report
Not enough suitable staff
seriousThere were not enough staff available or safely deployed. Staff were not always able to give people the supervision and personal care they needed.
“There were not enough staff available or deployed for people to keep them safe.” from the report
Poor food and drink support
seriousPeople were at risk of weight loss and choking. Staff did not always understand specialist or diabetic diets, and food was not always made accessible or replaced when needed.
“People were not supported to have a healthy diet.” from the report
Mental capacity processes not followed
seriousSome people received medicines without the required capacity and best-interest decisions. Staff did not have a clear understanding of the relevant legal safeguards.
“The principles of MCA continued not to be followed.” from the report
Weak leadership and checks
seriousThe home's audits and management systems did not identify or fix serious problems. Staff were unclear about their roles and the home was described as disorganised.
“There was a lack of oversight and effective systems of governance in the home.” from the report
Questions to ask them, based on this report
- 01What urgent conditions have been imposed on the registration, and what actions have you completed in response?
- 02How do you now make sure every person's risks, care plans and diet instructions are up to date and followed?
- 03How many staff are deployed on each shift, and how do you check there are enough staff for people's individual needs?
- 04How are medicines, pain relief, liquid medicine opening dates and stock checks now monitored?
- 05What training have staff completed on safeguarding, dementia, choking risks, mental capacity and care planning?
This was a focused follow-up inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed. This explanation was written from the published report of 14 May 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
An earlier report, explained
What inspectors found, March 2024
Inadequate and still in special measures; inspectors found ongoing risks from falls, choking and delayed medical support.
This was an unannounced targeted inspection on 14 December 2023. It looked only at risk management, people's health when it deteriorated, and clinical leadership for people receiving nursing care. Inspectors spoke with people, relatives, managers and staff, and checked four care records.
Inspectors found that risks from falls and choking were still not managed reliably. Care plans were not always up to date, prescribed safety equipment was not always used, and staff did not always complete health checks when people became unwell. This could delay medical help.
The home also did not have effective systems to identify and correct safety problems. The overall rating remains Inadequate and the home remains in special measures. The two areas checked were marked 'Inspected but not rated' because this was not a full review of those questions.
What inspectors praised
Personal space
The home provides people with their own bedrooms and shared communal areas.
“People have access to their own bedroom along with communal spaces including lounges.” from the report
Support brought in
The provider had brought in external consultants to help make improvements, although inspectors found that this had not yet dealt with the serious ongoing concerns.
“The provider had employed consultants to work at the service to support with making improvements.” from the report
What inspectors were concerned about
Falls and choking risks
seriousRisks were not managed consistently. Equipment intended to reduce falls was not always used, and action was not effective after repeated falls.
“Risks to people's safety continued to not be consistently and effectively managed to protect people from the risk of significant harm.” from the report
Delayed response to deterioration
seriousHealth checks were not always completed when people became unwell. This could delay identifying when medical advice was needed.
“This resulted in delays in identifying when medical advice and support was required.” from the report
Medicines accessible
seriousInspectors found prescribed medicines were still accessible in a person's bedroom, despite an earlier safeguarding investigation identifying this risk.
“During our inspection, we identified this medicine was still accessible to people in the person's bedroom.” from the report
Weak clinical oversight
seriousManagers and the provider did not reliably observe care or review records, so they failed to identify and address serious safety concerns.
“There was no effective clinical oversight at the service and managers and the provider had failed to identify and take prompt action to the unsafe care being provided to people.” from the report
Questions to ask them, based on this report
- 01How are you now preventing falls and choking for people receiving nursing care?
- 02How do staff identify and respond when a person's health starts to deteriorate?
- 03How do you make sure care plans include visiting professionals' advice and that staff follow it?
- 04What has changed since the inspection to ensure prescribed falls equipment is used every time?
- 05How does the condition preventing nursing care affect the care and admissions you can provide?
This was an unannounced targeted inspection of risk management and clinical leadership for people receiving nursing care; it did not assess all parts of the five key questions, so the overall Inadequate rating carried over from the previous inspection. This explanation was written from the published report of 5 March 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Swan House
6 rated inspections over 9 years: the service has slipped, from Good to Inadequate.
- May 2024Inadequatecurrent ratingSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2024Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022
Registered with the Care Quality Commission on 10 May 2022.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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