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 requires improvement. At this assessment the rating has remained 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 legal regulation in relation to record keeping and good governance

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

There had been a number of changes to the management of the home since our last assessment in July 2025. Following that assessment, the registered manager left and the deputy manager stepped up on an interim basis. A new registered manager commenced employment at the end of December 2025, so had only been in post a few months when this latest assessment took place. Possibly due to being new, the majority of people and relatives we spoke with, were unsure who the new registered manager was. None of the relatives had met them yet.

Staff provided mixed views on leadership and whether they felt supported. Some staff told us support came from their peers, others referenced the deputy manager, who worked on the floor at times, so was a more visible presence. Staff told us there was minimal provider involvement in the home, with them rarely seeing any representatives. Comments included, “I can’t give a proper judgement on [registered manager] yet, as they are fairly new and we don’t tend to see then on the floor, they are usually in their office, we don’t see [provider] here very much” and “I feel able to speak with [deputy manager] as I know them well and see them around the home a lot.”

Although the majority of people and relatives did not know the registered manager, they did tell us the home was well run and everyone we spoke with said they would recommend it to others. Comments included, “From what I have seen everything runs smoothly. They have good quality staff, who work well together” and “I would say so the home does everything it should do. I would recommend it because [relative] has said it is a good place to be cared for.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider’s governance systems and processes were not robust. They did not always act timely to address shortfalls in practice, or ensure changes made were sustained over time.

As referenced in the safe, effective and responsive key questions, various issues with record keeping and completion of monitoring charts were identified at this assessment. A number of similar issues were noted at the previous assessment in July 2025. This indicates significant shortfalls in the provider’s governance processes.

The provider had recently introduced a new auditing and governance system, with audits falling under 4 categories; residents, environment, team members and operations. The majority of new audits ran from January 2026, though we noted some older ones on the system dating back to November 2025. However, prior to this date, the provider was unable to demonstrate what audits and checks had taken place, as they could no longer access the previous system used for this purpose.

A number of the issues we identified at the assessment had already been picked up by the provider’s new internal governance processes. However, it was unclear whether improvements had yet to be made, or they had been but had not been sustained, as they remained an ongoing cause for concern.

Some issues we found had not been identified by the provider, with audits covering these areas indicating there were no issues. For example, nutrition audits had not identified a lack of guidance around fluid intake levels, nor that people’s intake was low. Pressure care audits stated repositioning schedules were being followed and documented, which was contrary to our findings. A number of audits had yet to be completed or had not been completed as often as stated. For example, only 4 daily walk rounds had been done since November 2025, and none since January 2026.

Sample sizes for some audits required consideration, to ensure the provider collated enough data to provide a reliable view of practice. For example, despite 44 people currently living at the home, oral care audits had often only involved checking 1 or 2 people per unit. The resident appearance audit had been completed on just 1 person.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider used an action / improvement plan on which issues identified through audits was added. Some of the time frames for completion were lengthy, for example 5 or 6 months, which may have accounted for why shortfalls were still present, despite being picked up via auditing several months ago.

Some actions had not led to the expected improvements, with limited information available to explain what had been done to drive improvement, and what else would be tried if this was not successful. For example, the January 2026 falls audit had indicated more frequent monitoring of lounges and bedrooms was required, as this was where most falls had occurred. It was not stated how this increased monitoring would be achieved and the February 2026 audit indicated falls in both areas had increased slightly.

A lessons learned document was shared with CQC for review, which covered an 8 month period from August 2025 to April 2026. It was not clear whether this was a one off document, or a process which would be completed on a regular basis. Rather than contain specific and person-centred learning of incidents or accidents which had occurred, the document provided more generalised actions such as to refresh falls risk assessments, review care plans, complete walk rounds of the home. The document focused on what processes should be followed and what checks should be done, rather than looking at what went wrong and what could be done better.

A monthly improvement plan was also shared with us, which covered the period October 2025 to April 2026. As the document was a ‘monthly’ improvement plan, we asked for copies for the last 6 months. The deputy manager informed us whilst this document would be done monthly moving forwards, this was the first time it had been completed, hence why it covered a 6 month period.

The improvement plan stated there were 24 ongoing actions and 4 key priority areas: medicines, equipment, record keeping and infection prevention and control. Some actions on the plan referenced documentation or processes we did not see or were provided with on assessment. For example, an action under ‘care planning’, stated daily checks and audits of the providers electronic care planning system were in place to monitor and support improvement. We saw no record of daily checks or audits of this system being completed. Rather than being a working document, this improvement plan was more a report detailing areas of improvement, what had been worked on, what still needed to be addressed, and what plans were in place to drive improvement. As detailed in this report, the majority of improvement areas still required work.

The provider had introduced or were rolling out a number of innovative systems, to support learning and development. For example, a computer programme the provider had called HECTOR, which analysed data from the care planning system, identified issues, generated suggestions and helped drive improvements. Another was called EDDIE which would act as a performance tool for managers and provide key information on a range of areas including staffing, quality and compliance.