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Date of assessment 11 November 2025 to 15 December 2025. Swallowtail Place is an independent living scheme in Acle, Norfolk providing care and support to tenants who live in their own self-contained apartments within the scheme. The scheme has 58 apartments in total with one and two-bedroom options available. At the time of the assessment, the service was providing regulated activity of ‘personal care’ to 44 people within their flats. This was the first assessment of this service, prompted by a review of the information we held about this service. This included concerns raised regarding poor care people were receiving, and poor governance within the organisation. The provider is commissioned to provide personal care at the location for 24 hours a day. We carried out unannounced visits to the registered office within the site on 11 November 2025 and 19 November 2025. We looked at all 5 key questions with all quality statements being assessed. We found that Swallowtail Place was providing an inadequate service to the people who used it and was not meeting its regulatory obligations. This assessment found the provider to be in breach of two legal regulations relating to safe care and treatment, and governance. The provider did not have an effective quality assurance and governance system in place, which had resulted in shortfalls that placed the people who used the service at risk of harm. Peoples risks had not all been identified and mitigated, and where risks had been identified, their management was poor. Lack of immediate action following falls meant that a person continually came to harm. Care plans did not demonstrate people received person-centred care, and they did not contain enough information for staff to be able to provide care and support that was safe, consistent, and effective. The provider’s governance system was not robust enough and failed to identify the shortfalls found at this assessment. For example, where quality audits had been completed, these failed to demonstrate they were meaningful and effective. Medication audits reviewed had not identified the medication errors we found during the assessment. We asked the provider for an action plan in response to the concerns found at this assessment on 13 November 2025. The provider sent a robust action plan to address the shortfalls and mobilised a team of experienced managers and directors to support the service to drive urgent improvement. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. .
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