Shawcross Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of a legal regulation in relation to governance at the service.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a clear set of values which were understood by the leaders and staff. These were ‘we are there for each other’, ‘we are positive and light-hearted,’ ‘we are authentic’ and ‘we create relationships.’ Some staff knew what the values were. We observed some values posters within the home. We observed the values being reflected in daily care and decision making.

Most staff we spoke to felt respected, included and valued. There was a culture which promoted equality, diversity, and inclusion for staff and people. Staff told us they could raise concerns without fear and there was evidence of openness and transparency with people and their families when things go wrong. One staff member said, “The culture here is very good and [registered manager] is brilliant.”

The different teams and units generally worked well together with a shared sense of purpose. We had been told by some staff how there had been some divisions between staff members, but the registered manager was aware, and the human resources team were supporting with restoring the culture. We observed evidence of joint working with people and their relatives to achieve outcomes.

The registered manager understood the context in which the provider delivered care, treatment and support. They embodied the culture and values of their workforce and organisation. However, they did not always have effective oversight of the service.

The registered manager demonstrated compassionate leadership and a clear commitment to promoting a positive, person-centred culture. However, while these leadership qualities were evident, the registered manager did not always maintain effective oversight of governance systems and processes which is documented further under good governance. We acknowledged some of these shortfalls may have been impacted by absences within the leadership team.

The registered manager was present within the service. They engaged directly with staff, people using the service and relatives. We witnessed an example in which the registered manager demonstrated empathy, respect and understanding to relatives during a sensitive situation.

The registered manager actively supported training and career progression, although appraisal compliance needed improvement.

Most staff told us they could approach leaders with questions or concerns. A member of staff said, “[The registered manager] is very approachable. [The registered manager] is always around and I feel I could go to [them] with any concerns.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager took any concerns raised by staff seriously and investigated promptly.

Staff knew how to raise concerns internally and externally. They felt confident they could raise issues with the registered manager without any fear of negative consequences. A staff member said, “If I have an issue, I bring it up with management and it always gets dealt with.”

The provider ensured staff had access to a ‘Whistleblowing’ policy which clearly outlined the procedure and responsibilities of staff in raising concerns.

The service ensured there were posters regarding how to speak up in the staff room.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The providers recruitment processes which we reviewed were fair, transparent and free from discrimination.

Staff, including leaders, received regular equality, diversity and inclusion training.

Staff, from all backgrounds, told us they had equal access to progression opportunities and felt everyone was treated equally; they felt valued and respected. The provider also ensured there was diversity in senior roles.

Staff told us the registered manager would always attempt to accommodate their needs if they needed to work flexibly. The registered manager explained how they complete risk assessments and make reasonable adjustments for women when they are pregnant.

The provider had an equality, diversity and inclusion policy from 2017. As a result, the policy did not provide up-to-date information regarding best practices and CQC expectations since then including the using data to address inequality and amplifying voices of those with poorer care experiences. Despite this, staff did not have any concerns regarding this area.

The provider did not have good governance. They did not share information about risk securely with others when appropriate.

The provider failed to notify us about some safeguarding incidents which were raised to the local authority. Some of the concerns included a serious injury which was unwitnessed and missed medication. If a provider does not notify us of serious incidents, it prevents us from assessing risks or ensuring appropriate action.

The providers oversight of the recording and completion of hourly checks, pressure care and personal care required improvement. While the care plans we reviewed were of a good standard, staff did not consistently record the completion of tasks as scheduled.

The registered manager did not maintain effective oversight system in key areas. We did not see evidence of an incident log, the safeguarding log required improvement and the DoLS tracker document did not contain details of new residents and staff had not followed up with the local authority. The staff appraisal compliance rate was low and staff recruitment files did not contain all the information required.

The governance systems regarding medication also required improvement. We did not see evidence of PEG protocols. The PRN protocols were not detailed and not person centred. Leaders were not completing regular checks for controlled drugs, and we found there had been errors regarding when CDs had been administered. The leaders did not have appropriate oversight of time sensitive medication being provided on time.

The provider ensured there were defined roles, responsibilities, and reporting lines for leaders and managers. However, during the inspection we found the registered manager was having to take on additional roles and responsibilities, due to her deputy manager not being present.

Managers and staff had regular meetings and audits were being completed with appropriate actions being identified. However, the audits being completed had not identified the concerns raised on the inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager told us they had a good relationship with the local authority and the quality performance officers. We saw evidence of this when the quality performance officer arrived at the care home to take referrals due to a fault with them being sent electronically.

The lead external provider manager from the local authority responded to our request for information and informed us the previous quality performance officer had a good relationship with the service and the registered manager. They went on to state the registered manager engaged well with the local authority and responded to enquiries in a timely manner.

The service had good relationships locally. The wellbeing coordinator was creating good relationships with local cafés and the salvation army. They had attempted to build relationships with local schools, but this was in its infancy.

The service had not sent out any external professional surveys, however the feedback we received from them was positive. The local hospice told us the registered manager regularly attended their monthly meeting and therefore kept up to date with local and national initiatives. They went on to inform us the service was open to making improvements when there were identified needs.

The provider did not always focus on continuous learning, innovation and improvement across the service.

The service had some systems in place to support learning and improvement; however, these were not consistently effective.

The service ensured they completed regular quality audits and identified areas for improvement which were acted upon, although as stated some of the audits did not identify shortfalls within the service. There was limited evidence of external audits taking place.

Staff told us lessons were learned from incidents, but there was limited evidence of structured reviews or formal learning being embedded into practice. The oversight of the themes regarding incidents needed improvement.

The new electronic systems for care plans and medications were not being used to their full extent. For example, peoples information had not all been transferred over successfully and we did not see evidence the reports from the medication system were being reviewed.

The service captured feedback from residents and relatives. For residents, staff engaged with them daily, and they had access to quarterly residents’ meetings. Relatives also attended meetings but mainly provided feedback when they visited. We observed positive interactions between the registered manager, the staff team and relatives.