This unannounced inspection took place on the 2 and 3 July 2018. During the last inspection in December 2016 we had concerns the service was not complaint with Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were insufficient staff to meet people’s needs and the provider did not have a robust quality

assurance system in place to effectively monitor the safety and quality of people's care.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and well led to at least good.

During this inspection we found there were sufficient numbers of staff to meet people’s needs, however, we still had concerns about the quality assurance systems in place to monitor the service.

Swan House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Swan House accommodates up to 32 older people. The home is split over two floors, each with16 places. All rooms have en-suite accommodation. The downstairs accommodation is provided for people who live with dementia. The first floor provides residential care. At the time of our inspection there were 28 people living in the service. The service is managed by a registered manager.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found some concerns with the safety of the service these included lack of precautions to prevent the contamination of food and the spread of infection. These included, packaging of food, which was not sealed, food containers left open, no use by dates on decanted food stuff and a lack of protective equipment when handling food. This meant poor hygiene standards in small parts of the kitchen placed people at risk of infection.

We also found the external environment placed people at risk of falls due to uneven paving. In addition a lack of sun shade meant people would be exposed to the sun and at risk of sun burn. Duck excrement in the graden meant the risk of infection spread by flies was increased.

Medicines were administered safely by trained staff. Improvements to the recording of medicines stock were to be implemented to ensure potential errors could be easily identified..

Staff received support through supervision, appraisals, training and staff meetings. Staff told us they received adequate training to fulfil their role.

The service was compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the service had policies and procedures in place to support this practice.

People’s dietary and health needs were taken into consideration and where appropriate, external professionals were contacted to provide support to staff and people. Care plans reflected advice given.

Staff were caring and people appreciated their support. Healthy relationships had been forged with staff who treated people with respect and protected their dignity. People appeared well cared for and their preferences in relation to the support they received was clearly recorded.

The service was complying with The Accessible Information Standard. Where people had communication or sensory difficulties the service sought ways for them to access information in a way that was suitable for them.

The service treated people equally regardless of their gender or lifestyle. P

We undertook an unannounced inspection of Swan House on 29 December 2016.

Swan House provides accommodation and care for up to 32 older people. The home is split over two floors, each with16 places. All rooms have en-suite accommodation. At the time of the inspection there were 25 people living at the home. The home does not provide nursing care.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection the registered manager was unavailable. We therefore spoke with one of the deputy managers and the Head of Buckinghamshire Services for Heritage Care.

At the last inspection on 23 April 2014 the provider was in breach of Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010. Assessing and monitoring the quality of service provisions. This is equivalent to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We asked the provider to make improvements to how they recorded audits in the home and any subsequent actions.

The provider sent us an action plan outlining the actions they were going to take. At this inspection we found improvements had been made and the provider had completed these actions.

People and staff told us there were not always enough staff on duty to meet people’s needs. People gave us examples of how they had been kept waiting for care and staff told us sometimes they struggled to meet people’s needs due to lack of staff.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role.

People and their families told us they felt safe at Swan House. Staff understood their responsibilities in relation to safeguarding people. Staff received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the authorities where concerns were identified. There were robust management systems in place of people’s medicines and people received their medicine as prescribed.

Some people benefitted from caring relationships with the staff. Other people told us they felt at times staff were not always caring toward them. People and their relatives were involved in their care and people’s independence was actively promoted. Relatives and staff told us people’s dignity was promoted.

Where risks to people had been identified, risk assessments were in place and action had been taken to manage these risks. However, people’s care plans had not always been updated with any changes of risks to people. Staff sought people’s consent and involved them in their care where possible.

People and their families told us people had enough to eat and drink. People were given a choice of meals but their preferences had not always been respected. This was because proposed changes to the lunch time food had not been implemented. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

Professionals and people told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided, but these were not always robust as they had not identified areas of concern at the inspection. Learning needs were identified and action taken to make improvements which promoted people’s safety and quality of life. Systems were mainly in place that ensured people were protected against the risks of unsafe or inappropriate care.

Staff spoke positively about the support they received from the Registered Manager and all of the team at the home. Staff supervisions wer

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

People were cared for in an environment that was safe and protected them against the risk of harm. One person told us “I feel very safe here.” We saw the environment of the service was well maintained and ensured people’s safety and welfare. Safeguarding posters were available throughout the home to ensure staff, people who used the service and relatives knew who to contact if they had concerns about peoples safety and wellbeing.

Is the service effective?

People’s care plans reflected their care and treatment needs and corresponded with what staff told us about their care needs. Medication was administered in a way that was intended to ensure people’s safety. Where errors had been made, the provider had a system in place to ensure staff were retrained to ensure people’s welfare. People could be sure they were supported by staff who were suitably qualified and vetted to undertake their roles.

Is the service caring?

We saw positive interactions between staff and people who used the service. We saw an example of one person who was not eating their lunch and they were offered a suitable alternative at their request. We saw one staff member reading and discussing a magazine with a person using the service. One person told us “The staff are all very kind.” We saw one person was supported to access the local community at their request.

Is the service responsive?

We saw the service was responsive to people’s needs. Where issues were addressed such as dietary needs or people were assessed at risk of weight loss, this was managed appropriately and other professional input was obtained as required.

Is the service well led?

We saw regular audits where undertaken within the service, however this was not always clear who was responsible for actioning any issues that arose or a timescale for when this would be done. Reviews and keyworker meetings were undertaken with people who use the service however we found no evidence of these meetings being undertaken. The provider had a system in place to identify issues however this were not always evidenced as being acted upon to ensure the quality of the service provision.

We spoke with people and observed care in one care area for people with dementia. We saw staff treated people with respect and provided guidance and support when it was needed. People had access to a safe garden. The people we spoke with expressed a positive view of the service. A relative described it as good. We saw that care plans included the information required to meet people’s needs. We found some gaps in falls risk assessment and in the evaluation of care plans. The service liaised as necessary with hospital and community health services.

Support for staff had improved. The service had a programme of supervision, meetings and appraisal. We saw team meetings had taken place, supervision was being established and there were plans to appraise all staff by the end of June 2013.

Procedures for monitoring the quality of the service included risk assessments, monitoring of complaints and incidents, reports to senior managers, audit of activities, and an annual survey. A monthly summary of accidents and incidents had been introduced to identify patterns of such events and indicate where action to reduce the risk of such an occurrence was required. The service had been inspected by an environmental health officer (EHO) in January 2013 and been awarded five stars for standards of food safety. We found records relating to people’s care, complaints, accidents, and health and safety were accessible and in good order.

People told us staff were helpful and provided help and support when required. One relative we spoke with told us that while staff were supportive they did not always pay sufficient attention to the detail of care. A visiting health worker who knew the home well told us that in their experience people were well supported and their privacy and dignity was respected.

We talked to a number of people using the service and to one carer who was visiting.

People using the service expressed satisfaction with the food, standards of cleanliness, and with the care provided by the ‘regular staff.

People expressed dissatisfaction with shortages of staff, with some ‘part-time’ staff, with the positioning of a bed in a room, the nature of the support provided to one person at times, and, on one occasion, a visitor finding a medicine tablet on the floor in his relative’s (the person using the service) room.