CQC report explained · a residential care home
What the CQC found at Shipdham Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2019
Shipdham Manor was rated Good; inspectors found kind, safe care, with some worn flooring and restraint training needing attention.
This was an unannounced inspection on 7 May 2019. Inspectors spoke with people living in the home, relatives and staff. They reviewed care plans, medicines records, recruitment files, training records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives gave very positive feedback. Inspectors saw warm care, enough staff, well-managed medicines and support that reflected people's needs and preferences.
There were some areas to improve. Flooring in parts of the home was worn or uneven and could cause trips. Regular training on a restraint technique was not scheduled, although the manager updated the care plan and booked training after the inspection.
The previous inspection was also rated Good, published in October 2016. The home remained Good at this inspection.
Kind and respectful care
Inspectors observed warm, compassionate support. Staff knew people well and respected their privacy, choices and independence.
“We observed warm and compassionate care which demonstrated strong relationships and understanding of people's needs and preferences.” from the report
Enough staff
There were enough staff to meet people's needs promptly. Staff had time to talk with people, and no agency staff were being used.
“There were sufficient staff to ensure people's needs were met quickly throughout the day.” from the report
Personalised support
Care plans included people's life histories, interests, preferences and dislikes. People could choose aspects of their daily routines and activities.
“The provider had recorded each person's personal history, their interests, preferences and dislikes.” from the report
Good management and learning
The home had regular audits and used incidents and feedback to improve care. Inspectors found a strong sense of teamwork.
“The provider maintained an 'incidents and accidents log' which the registered manager reviewed regularly to look for patterns and themes.” from the report
Dementia-friendly setting
The home had accessible communal spaces, a secure garden and signs and objects designed to support people living with dementia.
“This included an internal garden room with a bench and landscape decoration; a working small shop decorated in a 1950's style” from the report
Worn or uneven flooring
needs fixingInspectors found worn or uneven flooring in several areas. This could create a trip hazard. The home had budgeted for replacement and was waiting for quotes.
“The flooring in a number of areas within the home was worn or uneven which could present a tripping hazard.” from the report
Restraint training
needs fixingA minor restraint technique was being used appropriately for one person, but regular training was not scheduled. The care plan was improved and training was booked after the inspection.
“However, no regular training on the use of restraint was scheduled and senior staff were expected to cascade how to use the restraint technique to new staff.” from the report
Some tired decoration
minorSome people's bedroom decoration was tired, especially where they had lived in the home for a long time.
“Rooms were suitably personalised, but some people's rooms décor was tired, particularly where people had been resident a long time.” from the report
- 01What flooring has been replaced since the inspection, and which areas are still waiting for work?
- 02What training do staff now receive before using the restraint technique mentioned in the report?
- 03How are individual care plans reviewed with residents and their families?
- 04How quickly can staff usually respond to call bells, especially at night?
- 05What activities and outings are currently available for someone with dementia and their particular interests?
This was an unannounced planned inspection covering all five CQC questions, and all five ratings remained Good from the previous inspection. This explanation was written from the published report of 27 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2016
Rated Good; inspectors found kind, safe care, with some minor concerns about cleanliness, privacy and offering choices.
This was an unannounced inspection on 10 October 2016. The home provided accommodation and personal care for up to 42 people, with 41 people living there on the day. Most were living with dementia. Inspectors spoke with people, relatives, staff and managers, observed care, and checked care, medicine, recruitment and quality records.
The inspectors found enough staff, safe medicines practice, suitable training and good support with food, drink and healthcare. Staff were described and observed as kind, patient and respectful. People's care was planned around their needs, and activities were available.
There were some issues to address. One corridor and a bedroom had an unpleasant odour, and a mattress and pillowcase were not clean enough. Some people were not offered a choice of meal or drink, and staff discussed one person's nutritional needs in front of others. The manager acted straight away on the cleanliness issue and said the other matters would be addressed.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found the service meeting the relevant standards at the time of this inspection, although the report still identified areas for improvement.
Enough staff
Inspectors saw enough staff available to respond promptly when people needed help. Staff were not rushed and had time to spend with people.
“There were sufficient numbers of staff on duty to keep people safe and to meet their needs.” from the report
Safe medicines
Medicine records showed that people received their medicines as prescribed. Medicines were stored securely and staff had their competence checked.
“All of the medicine records that we checked indicated that people had received their medicines as requested by the person who had prescribed them.” from the report
Kind and respectful care
Staff were observed supporting people calmly and compassionately. They explained moving and personal care tasks and encouraged people to do what they could for themselves.
“All of the staff were observed to support people in a kind and compassionate manner.” from the report
Individual support and activities
Care records included people's needs and preferences, and staff knew people well. A range of activities and sensory items was available, including music, reminiscence and outings.
“There were a number of different activities that people could participate in to enhance their wellbeing.” from the report
Cleanliness and odour
minorMost of the home was clean, but one corridor and two rooms had an unpleasant odour. A mattress and pillowcase were not clean enough. The mattress was replaced immediately.
“When we checked one person's mattress on their bed, we found that this had not been cleaned sufficiently to decrease the odour.” from the report
Choices at mealtimes
needs fixingSome people were not offered a choice of meal or drink, and were not shown the available options. The manager said pictures of meals were being prepared to help people choose.
“However, we saw that some people were not offered a choice of meal at lunchtime.” from the report
Privacy during discussions
minorInspectors saw staff discuss one person's nutritional needs in front of that person and others. The manager agreed to remind staff to hold these conversations privately.
“The staff had not attempted to hold the conversation privately.” from the report
People entering bedrooms
needs fixingOne person said other residents sometimes entered their room and this made them feel worried and unsafe. The manager was aware and was working with the person to resolve it.
“Some residents have walked into my room. I can sometimes get them to leave but this makes me feel worried and a bit unsafe.” from the report
Complaint information
minorPeople and relatives said they did not remember whether there was a formal complaints process. They felt able to raise issues with staff, and the recorded complaints had been investigated.
“People and relatives told us they could not recall whether there was a formal complaints process to follow should they wish to make a complaint.” from the report
- 01How do you now make sure every resident is offered a choice of meal and drink in a way they can understand?
- 02What checks are carried out to prevent unpleasant odours and to make sure mattresses and bedding are clean before beds are made?
- 03How do you protect people's privacy when staff need to discuss their nutritional or other care needs?
- 04What is the current approach when residents enter another person's bedroom and make them feel unsafe?
- 05Where can residents and relatives find the formal complaints process, and how are they told about it?
This was an unannounced inspection of the overall service, covering all five CQC questions and the overall rating. This explanation was written from the published report of 28 October 2016 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Shipdham Manor
2 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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