Archived: Shawcross Care Home

Updated 16 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.

This inspection took place on 24 February 2021 and was announced.

Updated 16 March 2021

We carried out an inspection of Shawcross Care Home on 10 and 11 October 2018. The first day of the inspection was unannounced.

Shawcross Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is located in Ashton in Makerfield and provides residential and nursing care. The home is divided into two separate units, one for nursing care and one for people living with a diagnosis of dementia. The home can accommodate up to 50 people. At the time of the inspection there were 48 people living at Shawcross Care Home.

The home was last inspected on 19 July 2017, when a focussed inspection was carried out, which looked at the key questions of safe and well-led. This was because during the last comprehensive inspection carried out on the 20 and 22 March 2017, we identified two minor breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the management of medicines and good governance. We returned on the 19 July 2017, to check the progress the provider had made. During the focussed inspection, we found the provider had made the necessary improvements and was meeting all the regulations. As a result, we improved the ratings in the key questions safe and well-led, as well as the overall rating from requires improvement to good.

At this inspection we found the evidence continued to support the overall rating of good. However, we received mixed feedback about staffing levels and noted some discrepancy between the number of staff deployed each day and the amount the home indicated was required to meet peoples needs. As a result we had made a recommendation for the home to look at the allocation of staff on each unit, to ensure people’s needs are met both timely and safely.

At the time of the inspection the home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and staff provided mixed feedback about the number of staff deployed to meet needs. The home used a system to work out the number of staff required to safely meet needs based on people’s dependency levels, these are sometimes called dependency tools. We noted staff numbers allocated on the nursing unit were less than had been recommended by the dependency tool. Observations during inspection also showed staff struggled at times to meet needs, including their own need for a break, due to the number of staff deployed..

People we spoke with told us they were happy living at Shawcross Care Home, and aside from some concerns with staffing levels, felt safe. Checks had been carried out to ensure staff were suitable to work in a care setting with vulnerable people.

Staff were knowledgeable about the different types of abuse, how to identify these and report any concerns. The home had appropriate safeguarding policies and reporting procedures in place, which had been followed consistently. Accidents and incidents had also been logged, with actions completed to minimise the risk of reoccurrence.

The home was clean, well maintained with appropriate infection control processes in place. Staff had access to and wore personal protective equipment (PPE) to prevent the spread of infection. Checks and servicing of equipment, such as for the gas, electricity, fire safety, passenger lift and hoists were up-to-date.

Medicines were stored, handled and administered safely and effectively. Staff responsible for administering medicines were trained and had their competency assessed annually.

Staff completed both e-learning and practical training sessions. Staff spoke positively about the training provided, confirming they completed regular sessions. Staff also received supervision, albeit we found some inconsistencies in the frequency of completion. We saw the registered manager was taking steps to address this and ensure all staff were up to date.

The home was adhering to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), which is used when someone needs to be deprived of their liberty in their best interest. Where people lacked capacity to consent to care and treatment and did not have a legal representative to make decisions on their behalf, best interest meetings and decisions had been completed.

People spoke positively about the food and drink provided, with choices offered and people’s preferences catered for. Meal times were observed to be a positive experience, with people being supported to eat where they chose. People who required a modified diet, such as soft or pureed, received this in line with guidance from professionals, such as dieticians or speech and language therapists.

Staff were reported and observed to be patient, caring and kind. They knew the people they supported and how they wanted to be cared for. People told us they were treated with dignity and respect and offered choice within the daily lives. Staff were aware of the importance of promoting independence and encouraged people to do as much as they could for themselves.

Care files contained detailed care plans and risk assessments, which described how people wished to be cared for and helped ensure their needs were being met and their safety maintained.

The home provided a range of daily activities and events for people to participate in, facilitated by two activity coordinators. Activities were advertised on noticeboards throughout the home and people were asked and encouraged to join in. Involvement was captured within personal activity records.

People and their relatives were involved in the running of the home, through attendance of resident and relative meetings and completion of questionnaires. The home encouraged feedback both through internal processes and also via an external care home review website.

The home had a range of systems and procedures in place to monitor the quality and effectiveness of the service. Audits were completed on a daily, weekly, monthly or quarterly basis, depending on the area being assessed and covered a range of topics including medication, accidents and incidents, infection control and training. Provider level audits had also been completed, to provide further oversight of all aspects of service provision.