Swan House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People had their needs assessed and care plans put in place to meet them. Consent was sought from people receiving care. People were supported to meet their nutrition and hydration needs. Staff worked together to ensure people received the care they needed. People’s health needs were understood, and they received support to meet these and their care outcomes were monitored.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives were involved in assessing needs and developing care plans. One relative told us, "I was fully involved in the care plan, they consult us about any changes and they check that it is ok with [person's name]."

The registered manager described the preadmission assessment which was designed to capture information about the person coming into the home including identifying potential risks and their history. They told us this then led to developing risk assessments, management plans and an overall care plan.

People’s assessments and care plans were completed on admission and reviewed monthly or when things changed. Care plans were comprehensive and followed best practice using an electronic system. A new system was being introduced to involve more staff in assessing the needs of potential new admissions to the service. The aim of this was to identify if people’s needs could be met and people would be comfortable with the staff at the service.

People described receiving care that was based on best practice. For example, people described eating a healthy and balanced diet. One person told us the "The food is good, I always get a choice, they will prepare me something different if I don’t like what is on offer."

The registered manager told us they had systems in place to ensure people received the right support. This included checks on people's weight, the use of risk assessment tools and regular input from other agencies.

Nationally recognised tools were used to identify people’s risks and support needs. For example, appropriate tools were used to identify people’s nutrition and skin care needs. Results from these tools were then used alongside input from relevant healthcare professionals to create specific support plans for each person.

People described staff working well with other agencies to meet their needs. One person told us, "The staff know about my diabetes and what I can eat. They know about my catheter care, they can’t change it though, they have to get the district nurse for that." People were confident that staff were up to date with their care needs and shared information with one another. One person told us, "The staff have handover, they tell the next shift what has happened and all about us so they know what still needs doing."

Staff and the registered manager gave multiple examples of working well with other agencies.

Partner agencies confirmed the provider had worked in partnership with them to improve care planning, documentation and staff training.

A handover document was in place where staff recorded information about people living at the home. This included details about their care needs, any key medical information and updates. This was used to share information internally and externally when other health professionals were engaged in people's care delivery.

People had support to maintain their health and wellbeing and accessed health professionals when they needed to. One person told us, "I can see the doctor as I need, last week the optician was here and I am waiting for a tooth to be taken out at the hospital."

Staff understood people's health needs and described how they supported people to maintain their health. One staff member told us, "[Person's name] is diabetic, they manage this via medication and diet, we provide diabetic diet, he has full capacity and can make his own decisions about his diet." Leaders told us they had good links with people's health professionals and sourced referrals when needed.

Effective processes supported people to maintain a healthy life. The provider had systems in place to enable them to work with other health professionals. For example, they worked with a dietician to ensure people experiencing weight loss were monitored and received treatment. Health professionals confirmed any health concerns were escalated to the for a review.

People and their relatives reported improvements in health and wellbeing since moving into the home. One relative told us, "[Person's name] mobility has improved, they have to be encouraged."

Staff described how they monitored people’s progress and fed this into care reviews. The registered manager told us they kept a log of outcomes people had achieved since coming to the service.

Care plans were reviewed monthly and were updated to show where people had made improvements.

People’s consent was gained before staff supported them with their care needs. One person told us, "I direct my care, I tell the staff what I need and how I like things done."

Staff understood how to seek consent from people. They described how they assessed people’s capacity to consent and make decisions in their best interests. One staff member told us, "[Person's name] has full capacity to make all their own decisions, when people don’t have capacity, this is assessed and a best interest decision is made."

The assessment and care planning system included an assessment of people’s capacity to consent to care. The capacity assessments were decision specific and included relevant people in the decision-making process.