Shawcross 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 a legal regulation in relation to submitting notifications to the CQC.

This service scored 56 (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 did not always have effective oversight of accidents and incidents. There were forums which allowed staff to be made aware of lessons learned from safety events.

The service was unable to provide us with an incident log. Incident logs are crucial for identifying patterns and ensuring safety.

We reviewed the last 3 incidents; while staff completed the reports, the registered manager signed them off weeks later which delayed risk mitigation.

The service had forums, handovers and daily meetings to discuss incidents, and staff were encouraged to report concerns.

Relatives confirmed they were kept informed, and issues were resolved promptly. A relative said “There was an incident with my [relation]. The staff managed it quickly and adequately and kept us involved at all times. It has all been resolved now.”

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 evidenced how they had safely managed people’s transitions between care services. They involved people they supported in discussions around their care pathway and transitions. People were positive about their move into the home; one person said, “Everything seemed to be organised very well and when I arrived the staff went out of their way to make me feel at home.” A relative said “All the information regarding the support needs was sent over. The staff worked very hard to settle [person] in, they encouraged [person] to engage and socialise with other residents.”

The provider worked effectively with partners to ensure people were monitored as they transitioned between services. The local Hospice confirmed close collaboration, which ensured safe discharges and appropriate end of life referrals.

Staff told us they were made aware of new people coming into the service by senior staff or the registered manager. They said they had access to people’s care plans and would read these in advance of them moving into the service.

The provider ensured there were appropriate processes in place which ensured people were kept safe as they moved between services, including hospital passports which ensured continuity of care.

Relatives were satisfied with information sharing and the coordination of appointments, a relative said “The care home arranges everything regarding [person’s] needs; they arrange for the GP to see [person] and a nutritionist.”

The provider did not always share concerns quickly and appropriately. People’s Deprivation of Liberty Safeguards (DoLS) applications were not always followed up. However, staff did have a good understanding of safeguarding and had been trained.

The provider had not notified CQC, as required, about all the safeguarding incidents which were noted on their electronic safeguarding log sheet. Providers must notify CQC of all incidents which affect the health, safety and welfare of people who use services. This meant the provider was not meeting their legal responsibilities. This has implications for safeguarding, as it undermines external oversight and the protection of people using the service.

The providers recording of safeguarding incidents, as per the safeguarding log form, was not comprehensive, which meant it was difficult to ensure all concerns had been appropriately addressed. There were entries which did not indicate whether the incident was open or closed and the date noted on the log had some entries dated when the incident had occurred and others when it had been submitted. The provider had not reported 1 of the last 3 safeguarding incidents which had occurred in June 2025 on the safeguarding log. In addition, the safeguarding log did not indicate whether a referral had been sent to the local authority, if CQC had been notified and the outcome of the concern or any actions taken.

The provider’s DoLS tracker was incomplete and not effectively maintained. This meant there was a risk people were being deprived of their liberty without the appropriate legal safeguards. We have reported this under good governance, but it also impacts on safeguarding, as people’s human rights were not fully protected.

The provider ensured staff and leaders had access to safeguarding training and policies and procedures which were aligned to the latest best practice; however, the Safeguarding Vulnerable Adults Policy did not include local contact details.

Staff knew how to identify safeguarding concerns and understood the process to raise concerns. They were confident concerns raised would be listened to and appropriate action taken.

People and relatives felt the home was safe and we observed people to be clean and well kempt throughout the onsite inspection.

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.

The care records showed staff were not always completing regular checks intended to monitor people’s wellbeing. In 4 out of 5 care records, we found gaps in hourly checks. In 1 of the care records, we also found gaps in repositioning (intended to reduce the risk of pressure damage) which was either not documented or not completed as planned. This put people at increased risk of harm and meant staff could not be assured agreed care interventions had taken place. Although we did not see evidence of actual harm, the failure to follow care plans exposed people to the risk of avoidable harm.

Staff ensured care records were detailed regarding specific conditions people presented with and emotional support required. A care record for a person with mental health conditions provided a detailed explanation of how to help calm and comfort the person. However, although staff were trained in Positive Behavioural Support, we did not find staff were completing Antecedent, Behaviour and Consequences (ABC) logs when behavioural concerns were identified. An ABC chart helps to understand patterns and triggers, ensures consistent person-centred responses and supports behaviour management planning.

Senior staff updated people’s care plans and risk assessments monthly, as part of ‘resident of the day.’ Risk assessments were detailed, fully up to date and consistently checked. Where necessary, we saw evidence external professionals were used to help support with a person’s risk.

Staff understood the risks associated with people. They said they had time to read the risk assessments associated with the people.

People and their relatives felt staff had the knowledge and experience to help them or their loved ones manage risks. People told us how staff were aware of their support needs including assisting them with their mobility. Relatives were aware of risk assessments completed and the outcomes of these including bed rails and wheelchairs being required. A relative said “The staff understand [persons] needs, for example they raise [their] legs to reduce the swelling.”

People told us staff responded well when others became emotional or distressed. Relatives agreed and one told us, “Recently we visited and there was a singer performing for the residents. A lady with dementia became distressed and confused, so they were taken away from the event to a quiet place at the side of the room and staff calmed her down, they were very competent.”

Staff said they did not have specific training to manage heightened emotional distress but would use distraction techniques.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Safety checks were completed with certification in place, to confirm utilities and equipment were safe to use; detailed records were kept of all equipment certificates and utilities supplies. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Portable appliance testing was up to date and equipment was serviced as required.

The provider ensured people had emergency evacuation plans in place and regular fire safety checks and fire drills were being completed. However, the provider did not have an up-to-date fire risk assessment completed, which falls short of best practice standards for ensuring effective fire safety management. We raised this with the registered manager who told us the providers internal audit team had informed them an annual fire risk assessment was not a requirement as regular fire safety checks were being completed.

People were cared for in an environment which was designed to meet their needs. The service was secure and had working electronic keypads to ensure people’s safety. The service had private bedrooms, en suite bathrooms, large lounges with dining areas on each unit, corridors which were wide and free from clutter and well-maintained garden areas. The provider ensured people had access to call bells. There was dementia friendly signage throughout the home including dementia friendly clocks, a description of the day’s weather via an image and signs on most rooms indicating what they were, including bathrooms and bedrooms. However, there were some signs on doors which were missing.

Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly. Staff told us there was enough equipment and was all in working order.

People told us they were happy with the environment. A person said, “I have no concerns, I have everything I need and if I need equipment or a wheelchair, they [staff] get it for me straight away.” Relatives agreed, for example a relative said, “The environment is very safe. Furniture in bedrooms is fixed to the wall, and the handyman checks that furniture isn’t damaged.”

The provider did not always ensure staff records contained all the information required. Supervisions were taking place, but appraisal compliance was low. The provider did ensure staffing levels met the providers dependency tool, although people, staff and observations told us more staff were required.

The provider did not always ensure staff records contained all the information required. We found some staff files were missing details about employment history and photographic identification; these are required to verify identity and suitability for the role. The provider added this to their action plan to complete in September 2025.

The registered manager provided a supervision and appraisal document. Supervisions were taking place regularly with staff; however, appraisals were not. In 2025, 4 staff had completed an appraisal.

The provider ensured staffing levels were based on the needs of people, as set out in their assessments and care plans. The provider had introduced a new dependency tool which identified the needs of the people, and the amount of care hours required daily/weekly. Rotas from the last 2 months showed staffing levels met the dependency tools requirements. Despite this being the case, we observed lengthy periods where people were sat in the lounge areas unsupervised. Staff, people and relatives we spoke with felt the service would benefit from more staff. Staff spoke about the nursing unit being very busy and it being difficult to support everyone when some people required 2 staff. Staff from the EMI unit told us the increasing needs of people meant they did not think the staffing was sufficient. One person said, “I think there could be more staff, as they are so busy, they are always on the run” whilst another person told us “I think they are short staffed, especially at weekends.”

The provider ensured staff had access to training which was relevant for the role. The compliance rate for mandatory training for most staff was over 80%. Staff told us they felt the training was thorough and helped them in their roles. The registered manager explained how some staff had recently been accepted on to the care home assistant practitioner (CHAPS) training which is a structured development programme which trains experienced workers to take on extended clinical responsibilities. These included taking clinical observations and administering medication. New starters completed a 2-week induction of their contracted hours in which they were supervised until they felt competent to work alone. Staff completed a 3-month probation period, to ensure they were right for the service and could deliver the quality of care needed.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and tidy with no malodours noticed. We observed cleaning schedules in the rooms throughout the home which were up to date. All people and relatives we spoke to told us they had no concerns regarding the cleanliness of the home. People said, “The home is spotless,” “My bedroom is cleaned every day, and the communal bathrooms are very clean too.” A relative said “Cleaning goes on all day long; no room is left untouched and bed sheets are washed very regularly too.”

The provider had clear policies and procedures in relation to infection, prevention and control (IPC). The registered manager completed daily walk arounds for the service which reviewed the cleanliness of the home. The service had allocated 2 staff members to be ‘IPC champions.’ These staff members attended meetings with the local authority’s IPC team and brought back any learning to the care home.

Staff had received training in infection, prevention and control and told us how they applied this in their day-to-day practice. We observed the environment to be clean and found adequate supplies of PPE (personal protective equipment) in place. The provider had an up-to-date infection, prevention and control policy in place. We found monthly IPC audits had taken place with good compliance.

Staff wore the appropriate personal protective equipment (PPE) and were bare below the elbow. Relatives told us they were updated if there was an outbreak of an infection within the home.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider did not consistently ensure that some ‘when required’ medicines had a supporting protocol to explain their use. Some written protocols did not always contain sufficient information to inform the staff on how to support people to take these medicines.

People who needed to have their medicines administered directly into their stomach through a tube, did not have robust clinical protocols in place to inform staff on how to prepare and administer these medicines safely.

Staff did not always administer medicines which need to be administered at specific times of the day at the correct time. This meant this medicine was not always effective in treating the condition it had been prescribed for.

Staff did not always administer controlled drugs at the appropriate times and did not always record the quantity administered.

The provider did not have a robust system in place for recording where on the body skin patches containing medicines were being applied. This meant the provider was not able to show these patches were being rotated around the different skin sites to comply with the manufacturer’s guidance.

The electronic recording system for medicines showed when people had missed or skipped their medications. In July 2025, a new person had not been prescribed a painkiller for over a month due to it not being on a repeat prescription from the doctor. This had been followed up by the provider, but we saw limited evidence of an alternative painkiller being used in its absence.

Regular audits of the medicines were being carried out; however, the robustness of these audits did not always identify people had not received their medicines as prescribed.

Aside from the above, overall, medicine administration records (MAR’s) showed people received their medicines as prescribed.

Medicines were stored securely and staff which administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely.

People’s medicines which required cold storage conditions were securely stored and at an acceptable temperature. Fridge temperatures were being measured appropriately and the records showed medicines were being stored at between 2°C and 8°C.

There was a process for medicines being administered covertly, including obtaining pharmaceutical advice from an appropriate healthcare professional.

There were 2 separate medication champions for the nursing and EMI unit who were responsible for the ordering of medication. All ordered prescriptions were seen and checked by staff.