Inspection on 15/11/05 for Shipdham Manor

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shipdham Manor 03/03/09

Shipdham Manor 19/02/07

Shipdham Manor 16/06/05

Shipdham Manor 06/12/04

Shipdham Manor 27/08/04

Shipdham Manor 08/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Shipdham Manor Chapel Street Shipdham Thetford Norfolk IP25 7LB Lead Inspector Mrs Geraldine Allen Announced Inspection 15 November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shipdham Manor Address Chapel Street Shipdham Thetford Norfolk IP25 7LB 01362 820939 01362 822036 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manorcourt Care (Norfolk) Ltd Mrs Margaret Woolnough Care Home 31 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (30) of places Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Thirty (30) Elderly people, of either sex, may be accommodated One (1) person, of either sex, who has Dementia may be accommodated. 16th June 2005 Date of last inspection Brief Description of the Service: Shipdham Manor provides residential care for thirty elderly residents, and one resident who is elderly and mentally frail. The home is owned by ManorCourt Care (Norfolk) Ltd. The home is discreetly divided into three small living groups. There are 23 single bedrooms and 4 shared bedrooms. All bedrooms are en-suite and are situated on the ground and first floors. There are pleasant gardens with safe walking paths and sitting out areas. car park is at the front and side of the home. Shipdham Manor is situated in the centre of the village of Shipdham on the Dereham to Thetford road and is close to all local amenities. The Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place during the day of Tuesday 15 November 2005. The recently appointed manager, Ms Helena Helendoorn and operations manager, Mrs Margaret Woolnough, provided information throughout the day. The home provided information prior to the inspection day. On the day of inspection, some records were looked at and residents and staff were seen and spoken to. The care records for 3 residents were looked at in detail and the residents spoken with. A total of 9 residents were spoken to, some of them in private. Ten completed questionnaires were received from relatives and visitors to the home. A further 10 completed questionnaires were received from residents and 3 from health professionals. The views expressed in the questionnaires are included in this report. Lunch was eaten with residents in the main dining room. The home was experiencing some heating and electrical problems on the day of inspection. Despite this, the inspection went ahead and staff were able to continue to care for the residents properly. Lunch was on time and residents were able to keep warm because of arrangements made by the manager and operations manager. Based on what was taking place during the day and opinions expressed by residents and visitors, this home provides a high standard of care in pleasant surroundings. What the service does well: The home has excellent relations with health professionals. The ability of staff to provide high quality health and social care to the residents is acknowledged by visiting professionals. Residents at this home enjoy exceptionally good lifestyles that they feel reflects how they wish to live. They have frequent contact with the local and wider community and are supported to go outside of the home to visit places of interest and to do their own shopping. Relatives and visitors to the home also feel welcomed. Residents spoke highly about the food provided at the home. As well as having freshly prepared meals, mealtimes are clearly a social activity that feels unhurried. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Residents have their needs assessed before moving into the home to ensure they can be met. This home does not provide intermediate care. EVIDENCE: The care of 3 residents was case tracked. Each care plan contained written assessments of their needs. Additional information had been obtained from health professionals and social services as necessary. The assessments provided a good picture of the residents’ needs and how they could be met. There was evidence that the needs assessment informed the initial care plan. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 & 11 There is a care plan for each resident that reflects their needs and how they can be met. Residents health care needs are met in a timely manner. Residents stated that they feel they are treated with respect and dignity. Residents receive sensitive and respectful care at the time of their death that is in line with their wishes and in accordance with health care advice and support. EVIDENCE: The care plans seen as part of this inspection were well written and contained all the elements of comprehensive care planning. The physical, emotional and social needs were considered and for the most part provided good information. There were some gaps, for example one care plan did not include information about the person’s sleep patterns or any vision, hearing and speech difficulties. Another care plan was not fully completed in respect of daily living. There were some long gaps between entries on the daily record sheet and it was not always possible to cross-reference some entries to health care interventions. The need to record daily information about social and emotional needs and Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 10 activity as well as care matters was discussed with Ms Helendoorn and Mrs Woolnough. There was evidence of regular care plan reviews but there is not always evidence that the resident was involved in the process where possible. Generally however, the care plans are well written and legible. Ways to develop the care plans and information recorded on the daily record was discussed. See recommendations. Two GP’s and 1 Community Nurse completed and returned questionnaires. One GP stated, “I have no doubt that my patients receive the highest standard of care at Shipdham Manor”. The Community Nurse stated, ”I have always felt the standards of care in this home are extremely high”. The care plans show that staff obtain advice and intervention from health professionals in a timely way. Instructions are properly recorded to ensure staff understand what is required of them. All residents who completed and returned questionnaires stated that they felt they were treated well and with respect. Those residents spoken to were highly complimentary of all the staff at the home. The interaction between staff and residents was observed throughout the day and was seen to be appropriate, friendly and warm. There was a great deal of laughter to be heard and people felt comfortable with the staff. Ms Helendoorn was also spoken of with warmth and affection. The care plans showed the wishes of residents at the time of their death. Evidence was received from a Community Nurse that the home cares very well for people at the end of their lives. She stated, “…We jointly cared for a lady through a long terminal illness to a peaceful and dignified death. At all times they [the home] acted with her best interests at heart and were able to communicate this to her family”. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Residents are able to enjoy a lifestyle that is relevant to them and can take part in activities in and outside of the home as they wish. Residents are able to welcome visitors when they wish and residents are able to have contact with the local and wider community. Residents feel they are able to exercise control and choice over their own lives. Residents enjoy a varied and nutritious diet that is well presented. EVIDENCE: Residents spoke about life at the home and described an enriching experience where they could take part in activities in and outside of the home. For the most part, residents felt they were able to have a lifestyle that was meaningful to them and that staff supported them to do so as necessary. One resident stated, “I am very comfortable and well cared for”. Another resident stated, “A wonderful place, I have no regrets in moving here”. Another stated, “I couldn’t wish for anywhere better”. Residents described the fortnightly shopping visits in the home’s minibus. They also spoke about the trips they had enjoyed during the summer months, including s Broads trip, a visit to the coast and an outing to Bressingham Gardens. On the afternoon of the inspection, there was a musical entertainment taking place that was well supported by residents. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 12 Residents confirmed that their visitors are always welcomed to the home and offered refreshment. This was observed during the course of this inspection. One returned questionnaire from a relative stated, “We are always welcome at Shipdham Manor and thank the staff”. Relatives are encouraged to be involved in events at the home and many posters about the home offer open invitations to relatives and visitors. Generally, residents felt they were able to exercise choice over their daily routines and that their choices were respected by staff. Residents spoke of choices around times of rising and retiring, where and how they spend their and with whom, and choices around food. Care plans reflected the choices expressed by residents and staff were aware of choices and preferences and worked hard to ensure they were respected. A meal was eaten with residents in the main dining room. This was a highly social occasion, with plenty of chat and laughter. The meal was well presented and residents described the choices available to them at mealtimes. They were very complimentary about the food. The meal provided was all homemade produce that had been freshly prepared at the home. The meal was of a high standard and clearly enjoyed by the residents who confirmed that this was the standard normally provided at the home. The cook is particularly commended for providing a high quality meal on time despite the many difficulties experienced during the day. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Although in a state of disruption due to essential building works, the home was well maintained. Two fire doors had been wedged open during a food delivery that prevented the doors closing when the fire alarms sounded. EVIDENCE: At the time of inspection, new heating boilers were being installed. This was causing considerable disruption for staff although residents stated they had not been inconvenienced beyond spending time in specific parts of the home where heat was available. During this inspection, the fire alarms sounded due to soldering being done by a heating engineer who was too close to a detector. Two kitchen doors had been wedged open and these were removed by Mrs Helendoorn to allow the doors to close. The doors had been wedged open by the cook as she was receiving a delivery of food. This was discussed with Mrs Helendoorn and Mr & Mrs Sharples and it is recommended they consider the fitting of automatic door Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 15 closers or Doorguards so that the doors can be left open safely. See recommendations. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 & 38 Mrs Helendoorn, who has recently been appointed, manages the home. Mrs Helendoorn is not yet registered with he Commission. The ethos and management approach of the service providers, operations manager and manager at the home ensure residents enjoy a happy and relaxed lifestyle. Residents’ financial interests are safeguarded by the homes practices. The health and safety of residents, staff and visitors to the home are protected by good practice. EVIDENCE: Mrs Helendoorn has recently been appointed as manager at Shipdham Manor and this was her first inspection at this home. There was evidence from residents that Mrs Helendoorn is very approachable, caring and attentive to Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 18 their needs. At the time of inspection, the registration process had not commenced and it is expected that Mrs Helendoorn will submit an application shortly. Throughout the inspection day, there was evidence that residents benefit from and enjoy the way they are able to spend their time at this home. There were many expressions of satisfaction from residents about the manager, staff, activity, food and environment. The home is commended. The way residents’ personal allowances are kept and recorded at the home was looked at. The practices used are safe and good records were seen although they would benefit from having 2 signatures for each transaction and a clearer running total. The running total for each resident is checked at every transaction and receipts are provided as necessary. See recommendations. The records in respect of fire safety and training and also accidents were seen and found to be up to date and in good order. Evidence was seen that the home is complying with recommendations made by the Environmental Health Officer. Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 X 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X x STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X 3 x X 3 Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the care plans are further developed to include daily recording of all physical, social and emotional issues. The involvement of the resident in their care planning and review should also be recorded. It is recommended that automatic door closers or Doorguards are fitted to the kitchen doors to allow for these doors to be kept open safely when food deliveries are received. It is recommended that two signatures are obtained where possible for each transaction made in respect of residents’ personal allowances. 2 OP19 3 OP35 Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shipdham Manor DS0000027399.V252880.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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