Shaws Wood Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good.

At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to managing risks to ensure people received safe care and treatment and the ways the premises and environment were managed safely.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager completed a monthly review of the service which included learning points. Analysis had been carried out by the management team to determine the root cause of incidents and actions were taken to prevent things happening again. For example, the registered manager had written to relatives asking them not to bring in bars of soap to the service. This was because they had reviewed an incident where a person living with dementia had ingested some soap. Relatives were requested to bring in shower gel to ensure everyone’s safety.
A staff member told us, “After each shift we have a handover where they talk us through what has happened on the previous shift and any key points to be discussed about residents. We also have a communication book which is read before starting your shift.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider was in the process of transferring written care plans and information on to an electronic care planning system. This would enable the staff team (when this transfer work is complete) to create a hospital passport. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. A person told us, “Staff will arrange if I need to see someone. They are sorting out a district nurse visit for me today as my legs are swollen and painful.”

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP. A staff member told us, “The surgery review people if we have referred them for health changes.” Relatives told us healthcare professionals were contacted when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe and were protected from harm. The management team had reviewed processes and learnt lessons from safeguarding incidents. We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Staff told us they were confident to speak up if needed. A staff member said, “I would report abuse to the senior on shift. I would come to CQC to report if I needed to.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s risk assessments had not always been updated to reflect their current needs. For example, a person’s skin integrity risk assessment showed their skin was in good condition. However, this was not accurate as the person had a pressure sore on their sacrum and another wound on their body that required monitoring. The person’s risk assessment did not state what pressure relieving equipment was in place. Some risk assessments had not always been followed. A person’s risk assessments highlighted a particular health and infection control concern. It detailed safe ways of managing this. We checked whether the risks had been mitigated as detailed in the plan. We found they had not. We reported this to the registered manager who took action to address the concerns.

Risk assessments for falls had not always been reviewed and updated in response to falls. Skin care plans did not reflect new information from skin assessments which had been undertaken by the pressure champion within the service. People had not always been repositioned as per their assessed needs. Staff told us they did not always have time to check if people had been repositioned as they should. A staff member told us that the new electronic system would help them alongside senior staff and the manager.

Risk assessments were missing for certain medicines in people's care records. These included medicines such as anticoagulants that may increase the risk of bleeding following a fall. These risk assessments were in place for the old paper based care plans and risk assessments that had yet to be transferred to the new system. These risks had not been added to the electronic system for the care records that had already been transferred. Although the new electronic system was not yet live, any risk assessments that had been completed had been printed out for staff to access.

Risks to people in relation to harm from constipation were not always well managed. Continence care plans did not specify how many days of not opening bowels triggered the use of intervention such as natural laxatives found in foods or as and when required medicines. There was no guidance for staff about when and how to escalate constipation concerns.

Records showed that relatives had been contacted when there had been incidents and accidents and actions had been taken. People told us they felt safe. However, a relative told us they were concerned for their loved one’s safety. This is because they had witnessed a person walking with purpose around the service who went into other people’s rooms. They had witnessed the person visiting their loved one and taking things from their room. They explained this happened in the day and at night, which had made their loved one anxious. We observed this happening in the day during the assessment. Actions had not been taken to reduce the risk of the person entering other people’s rooms.

Staff told us changes to risk assessments were shared across the team. Staff had a good awareness of people’s choking risks, and we saw them supporting people to sit up more to eat and drink.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. People were supported to move around the service safely and were supported to spend time where they chose. People were given food and fluid in a consistency which was in accordance with their assessed needs. The food was well presented, and people were observed to be enjoying the experience. Staff told us about safe ways of working with people which demonstrated they knew them well.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We observed some carpets and flooring around the service which required replacing due to stains and a strong smell. Most wash basins in the service were missing plugs and basins were not fitted with mixer taps meaning people had to choose between hot or cold water to wash with. We observed window frames upstairs in places were rotten. The provider shared their plans to sort these issues and explained they had been deferring undertaking these works for a number of years due to unexpected costs (such as replacement of fire doors to meet fire safety regulations) and finance issues from delayed and outstanding payments. There were no working baths at the service, which meant people who preferred a bath and people who would benefit from a bath were unable to have one.

A relative told us, “Furniture in rooms is dated, sometimes I have had to report areas where [person] might hurt themselves.”

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We observed there were enough staff on duty to support people. We observed call bells were answered quickly. However, people gave us mixed feedback about the staffing levels. Comments included, “It would be good to have a few more”; “There is [enough staff] but I don’t always like how they talk to me, they don’t seem to understand that I’m deaf. I think they could do with some training”; “I think so, I don’t have to wait long” and “During the day there is enough staff but not at night. I do have a buzzer so can call them.” Relatives told us, “During the day it seems ok, but not at night” and “In the week there is enough staff, not so many on at weekends.” We checked the rotas and there were fewer senior staff at the weekends but the same amount of care staff. Staff told us there were occasions when the service runs with less staff. Comments included, “I feel weekends are really understaffed. The residents’ needs are not being met and it’s not working”; “I think there could be more staff, staff work very, very hard in the morning and afternoon. We meet people’s needs but would meet people’s needs better if we had more staff as we don’t get enough time with them” and “We have fed it back to [registered manager] and [nominated individual] and asked them for more staff. They give the excuse that there is enough. Most people are double handed and only 2 staff are allocated to do all the double handed support. The impact is that people are not coming out of their rooms until lunch or after lunch.”

We had mixed feedback from staff about how frequently they received support through supervision and one to one meetings with their supervisors. Comments included, “My last supervision was done last month” and “Last one was done last year. I’ve not had one this year”. The management team had identified that supervisions had fallen behind so had put in place a new supervision schedule which was due to start in September 2025.

The training matrix showed that most staff had completed mandatory training. However, the training records showed that staff had not completed additional training to meet people’s assessed needs, such as epilepsy. Only 1 staff member had completed sepsis awareness training, 3 staff had completed catheter care training, and 4 staff had completed Parkinson’s training. After the assessment site visit the nominated individual told us a new trainer had been employed, and they would be rolling out additional training such as first aid and epilepsy.

Staff had been safely recruited. All required recruitment checks had been carried out and documents were all in date. The provider had retained copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The provider had shared concerns with appropriate agencies promptly. Some areas of the service required deep cleaning to control infection risks. There was a strong smell of stale urine in places. We observed that the laundry was not very organised with large volumes of dirty and clean laundry. These were separated appropriately. The build-up was because a tumble drier was out of action and awaiting repair. The nominated individual for the provider told us the drier had been deemed uneconomical to repair and approval had been made to gain a rental machine to replace it. The registered manager confirmed a dedicated laundry assistant has now been employed and the tumble drier was replaced within a few days of our assessment visits.

The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning. Cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. The kitchen areas were clean and well managed. We observed that the staff were using PPE effectively and safely.

Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “We have PPE cupboards dotted around the home for access. Staff aren’t the best at wearing PPE, but the manager will pull them up and tell them to wear it.” Another staff member said, “The majority of staff wear PPE.”

The provider had systems and processes in place to manage medicines, these were not fully robust, and some improvements were identified.

Medicines administration records (MAR) were not always clear. We observed staff had used a specific code on the MAR charts but there was no information about what this meant. For medicines given ‘as required’ (PRN), such as pain relief there were protocols in place, An exception was for a person who did not have one in relation to emergency rescue medicine they needed to help them if they suffered from an angina attack. Room and fridge temperatures were recorded to ensure medicines were stored at the correct temperatures. These had not always been recorded daily as they should have been.

Medicines were securely stored and timed medicines were given appropriately. The ordering process for prescribed medicine was effective, and we were able to reconcile medicines stock with prescribing. The management team carried out regular medicine audits.

People told us they received their medicines when they needed them. Comments included, “Staff support me with all my medicines I don’t have to worry about anything”; “Staff give me my medication” and “Staff sort all of that out for me and explain what it is for.”