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 requires improvement. At this assessment the rating has remained 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 the safe management of medicines

This service scored 59 (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 a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were documented and monitored on the provider’s electronic care planning system. A review of completed forms showed whilst some had been completed to a good standard, others lacked detail on actions taken and outcomes. No specific log was used to document incidents and accidents to provide an overview of what had occurred each month.

The registered manager told us they reviewed data every month to check for patterns and trends and then added this to the incident analysis reflections audit. However, these had only been introduced in January 2026 and the 3 completed to date contained limited analysis of each incident and limited lessons learned.

A falls audit had been completed monthly. One of the sections on this was analysis and patterns. However, limited information had been recorded in this section. For example, one audit stated a person had experienced 9 falls due to decline in condition. There was no further information such as what this decline was, why this had led to an increase, what had been done to try and reduce falls and if not successful why. As such, we were not assured the analysis process was robust.

A new complaints process had been introduced, with online complaints forms completed, which automatically pulled through to a complaints tracker. However, the registered manager told us they had not yet started to use this system. A paper-based tracker was still being used, which ran from August 2025 up to the present day. This tracker lacked detail and we noted not all complaints received had been added to this, which meant we were unsure whether action had been taken and the complaints resolved.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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. However, the recording of actions taken when safeguarding issues had occurred was limited and it was not clear if steps had been taken to prevent a recurrence.

The provider had an up to date safeguarding policy and procedures in place. Safeguarding alerts had been raised with local authority as required. Although all alerts had been documented on a safeguarding log, details of what had happened were very limited. There was no information on the log of what actions had been taken to keep people safe. The follow up / lessons learned column was blank for each entry, and we were unable to locate this information elsewhere.

Deprivation of Liberty Safeguards (DoLS) are a legal framework designed to protect people who lack capacity to consent to their care arrangements, and ensure any deprivation of their liberty is necessary, proportionate, and in their best interests. Providers are required to submit DoLS applications to the local authority where people lack capacity and are being deprived of their liberty in some way, for example, not being able to leave the care home without support. DoLS had been applied for as required, with logs kept to monitor applications.

Where people lacked capacity to make decisions about their care, the best interest process had been followed, although some people’s records had not been completed fully.

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.

Care records contained a range of risk assessments. Some were detailed and of good quality, others lacked detail, were contradictory and contained incorrect information. For example, 2 people’s call bell risk assessments stated it was appropriate for these to be in place, despite both people being unable to use them due to impaired cognition. For a person who displayed distressed behaviours, there was a lack of detail in their care plan and risk assessments on how to manage these behaviours. There was limited to no information about triggers, early warning signs, prevention strategies, best ways to provide support and what staff should do after an incident. This person often became distressed and subsequently physically aggressive during personal care tasks, but reasons for this had not been explored. The current management strategy had been to increase the number of staff who supported this task.

Where people used or required medical equipment or aids, safety checks had not been done consistently. According to monitoring charts in place, 1 person’s pressure mattress had only been checked to ensure it was working correctly 7 out of 21 days in April. Hoist, sling and wheelchair checks had also not been completed on a daily basis, to ensure they were in good working order and safe to use, before being employed by care staff.

The provider had recently introduced a new system called APRIL (actioning policies and risk assessments using insights and legislation) which had been created to support managers with the risk assessment process, especially for new admissions. Managers could type in a person’s needs, and the system would direct them to relevant policies and risk assessments.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

The provider was unable to evidence staff had received regular supervision and appraisal. The registered manager told us upon commencing their role at the end of December 2025, they had started to complete appraisals, known as guidance and development meetings, with all staff. To date they had completed 33 meetings. Once all had been done, they intended to carry out supervision meetings every 2 months. Staff feedback supported this, comments included, “I’ve had 1 guidance and development meeting. I think supervision is 3 monthly but not had one for at least 12 months” and “I had an appraisal a few weeks back, but nothing before this.”

The Health and Care Act 2022 states that all CQC registered providers must ensure their staff receive training on learning disability and autism, appropriate to their role. The Department of Health and Social Care have published specific guidance on how to meet this requirement. The providers training did not meet the required standards, with the e-learning offered to staff only being an introduction to learning disability and not covering autism at all.

Training completion was documented on a spreadsheet. This showed completion rates varied across staff members and training courses, with a number being under 80% and some below 70%. This included safeguarding adults training, infection control and fire safety. The provider’s training policy stated all staff needed to complete safeguarding children’s training. However, this course was not listed on the matrix which indicated it had not been provided. Staff told us they were required to complete training during working hours but often found this difficult due to being busy with people and had to fit it in as and when they could, rather than being allocated a set time. The provider confirmed they did not currently allocate set training time to staff but would look at this moving forwards.

People, relatives and staff provided mixed views on staffing levels within the home, with some stating there were enough and others saying more were needed. One person stated, “There are enough carers, someone is always around.” Whilst another person said, “No I don’t think there are enough staff. They are all extremely busy all the time. More staff would help as some people need more than one carer looking after them at a time.” Staff told us levels on the residential unit were okay, but it was more of a struggle on the nursing unit.

The provider used a system for determining staffing levels, known as a dependency tool. We found this to be confusing, as it indicated 8 carers were required in the morning (for the whole home), but only 4 carers were needed from noon onwards. This meant the home was operating with 4 more carers than required from 12pm until 8pm, as 8 were deployed all day. This did not tally with our observations. People’s need for support with mealtimes, personal care, mobility and remaining safe within communal areas, meant 2 staff per unit would not be sufficient.

Overall, staff had been recruited safely, with all required pre-employment checks completed and references sought.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Staff had received training to manage medicines and had their competency assessed, however not all nurses had completed additional training related to syringe drivers or enteral feeding. It was not clear how effective the competency process was given issues found during the inspection.

Medicines records did not always reflect that medicines were administered as prescribed. For one person, we saw staff had not omitted a dose when this was requested by an external healthcare professional. For another person, records showed staff did not follow the prescribers’ instructions for administration of an antibiotic.

Medicines records did not always contain accurate information when someone was allergic to a medicine. For two people, we saw no allergy status had been documented and for one of those people, discharge information supplied by the hospital indicated they were allergic to a medicine which staff had not recorded. We could not be assured there was a system in place to ensure allergy information was checked at the point of admission and any new information was acted on. This put people at the risk of receiving a medicine they were allergic to.

Record keeping for people who required thickener powder adding to drinks to prevent them from choking was poor. For one person, staff had not documented any use of thickener. For another person we found occasions when staff had not documented the use of thickener, and other instances where staff had documented using the wrong amount. We could not be assured people who needed their drinks thickened were having this done as prescribed and this put them at risk of choking.

Instructions for medicines prescribed to be given when needed (PRN) were available to staff when they administered medicines, but these did not always contain person-centred information that would give staff the information they would need. For one person who was prescribed medicine for agitation there was no information for staff on how they would present and how staff could prevent the medicine from being needed. On occasions when the medicine had been administered staff did not always document the reason why it had been used.

Although the service completed medicines audits and an action plan was in place, some of the issues found at the last inspection such as missing information in PRN protocols continued to be a concern. We could not therefore be assured audits and actions plans were effective.

Medicines were stored securely and areas used to store medicines had the temperature monitored and reviewed and action was taken by staff if it was recorded as being out of the recommended range.