Inspection on 16/06/05 for Shipdham Manor

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 15/11/05

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 IP25 7LB Lead Inspector Geraldine Allen Unannounced 16 June 2005 9:30 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 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 I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shipdham Manor Address Chapel Street, Shipdham, Thetford, Norfolk, IP25 7LB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01362 820939 01362 822036 Manorcourt Care (Norfolk) Ltd Mrs Margaret Woolnough Care Home 31 Category(ies) of DE Dementia, OP Old age registration, with number of places SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Thirty (30) Elderly people, of either sex, may be accommodated. 2 One (1) person, of either sex, who has Dementia may be accommodated. Date of last inspection 6 December 2004 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 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. The 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 SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted during the morning of 16 June 2005. The focus of this inspection was the staffing arrangements and the files of 3 staff were seen prior to speaking to them in private. Time was also spent with the manager and some newsletters and quality survey results were provided. Evidence has been gathered to show that this home gives excellent care. Residents were seen about the home and they appeared to be happy and busy doing what they wished. During the morning, the local Vicar came to the home and conducted a Communion service. A social gathering and sherry followed this in the lounge. There was a very happy atmosphere in the home, with residents looking cheerful and content. This was in line with the findings of the quality survey, which showed that responses to the questions asked were very positive, with most responses being either very good or excellent. The following questions were discussed and agreed with the manager: What the service does well: The home provides excellent care on an individual basis, with each person’s preferences and choices being sought and respected. Staff are very well trained and are given the opportunity to develop. The training records were seen and staff also spoke about what they had been doing to learn more about giving good care. Staff are well supported by the manager, senior staff and owners of the home. They are able to attend regular staff meetings and are given the time to spend talking with the manager and owners about any issues that matter to them. The manager has developed a very good quality survey that encourages residents, relatives and visitors to the home to say what they think about it and the care provided. A copy of the last survey shows very high levels of satisfaction. There is an excellent atmosphere in this home. Those residents seen were happy and smiling. There was plenty of laughter heard from residents and staff. All those people seen appeared relaxed and content. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 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 I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 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 standard(s) 1 & 5 Prospective residents have sufficient information to enable them to make an informed decision to move into the home. Prospective residents and their representative are able to visit the home before making a decision to live there. EVIDENCE: The home produces a brochure, containing information about ManorCourt Care and the home. The information is written in accessible language and is well laid out. Information about the homes aims and objectives and its statement of purpose are also included. Sufficient information is provided to give the prospective resident and their representative a flavour of life at the home and guidance in respect of such issues as independent financial advice. During the course of this inspection, the relative of a prospective resident had arrived unannounced to view the home. It was observed that full information was being given and answers to queries provided. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 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 standard(s) These standards were not inspected on this occasion. EVIDENCE: SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14 & 15 Residents are able to enjoy the lifestyle that suites them and takes account of their personal choices and preferences. Residents are able to maintain their contacts with family, friends and the wider community as they wish. Residents receive a varied and nutritious diet that reflects their preferences and dietary needs. EVIDENCE: During the course of this inspection, residents were seen in various parts of the home and engaged in different activities. The local Vicar provided a Communion service that was well supported by residents. It was noted that relatives and members of the local community had also attended. Residents enjoyed a glass of sherry and this was a social event clearly enjoyed by all present. The manager spoke of the contact residents are able to have with relatives, friends and the local community. This was seen during the inspection. Residents are able to exercise choice over their daily lives as far as possible. The manager and staff spoken to during the inspection provided anecdotal evidence to this effect. Residents are able to rise and retire when they wish. They are encouraged to make choices with support from staff as necessary. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 11 Residents can choose their meals from a range of alternatives. Choices are available at each mealtime and for the lunchtime on the day of inspection residents could choose between roast chicken, a vegetarian option, various salads and jacket potatoes. Special diets are also catered for. The catering manager plans and reviews menus and has received all relevant training to ensure residents receive nutritious food whatever their dietary needs. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 Residents are protected from abuse. EVIDENCE: Staff have received training in respect of adult protection and were able to speak with authority on the subject. The majority of care staff have now attained their NVQ at level 2 and/or 3, where adult protection issues are also included in the training units. All staff have been subject to criminal records bureau checks and these were seen on each staff file reviewed. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 26 The home is well maintained and kept clean and free of offensive odours. EVIDENCE: Those areas of the home that were seen were clean and tidy. Decoration was of a good standard and there were no offensive odours. Residents were able to access all areas seen during this inspection. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Staff are employed in sufficient numbers to care for the residents. Staff are well-trained and competent. The home has good recruitment procedures that protect the residents. EVIDENCE: The staff rota for the week of inspection was provided and this showed that staff are employed in sufficient numbers to provide care, undertake catering and keep the home clean. Staff turnover at this home is low and this has meant that residents benefit from a continuity of care from experienced staff. Three staff files were seen and these staff were then spoken to in private as part of the inspection process. The files were in good order and contained application forms and references (where appropriate), training record with certificates, appraisal records and also personal information. Supervision records were held separately in the managers, office. At previous inspections, ManorCourt Care has demonstrated a substantial commitment to staff development and training and evidence was seen that this continues to apply. This is an exceptionally well-trained staff group and the levels of achievement are highly commended. The annual training record was seen and demonstrated the wide range of relevant training being undertaken. This home has the added benefit of a qualified trainer in the form of the catering manager. She provides all staff working for ManorCourt Care with health & safety, food hygiene awareness and 1st aid training as part of the induction process and at each annual up date. The catering manager SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 15 described the level of consultation undertaken with the relevant bodies to ensure that the training content was appropriate. All staff wishing to undertake NVQ at either level 2 or 3 have now done so. The manager stated that 3 staff now have NVQ at level 3, with a further 4 currently working towards it. Seven staff have achieved NVQ at level 2 with a further 6 nearing completion. All at the home are commended for this achievement. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 & 36 The manager is qualified and competent to manage this home. She provides good leadership and encourages an ethos of openness and has an inclusive approach. The views of residents, relatives and visitors are actively sought and acted upon where appropriate. Staff receive supervision that is recorded. EVIDENCE: The manager is well qualified and has achieved her Registered Managers Award. She has a commitment to continuous learning and described various 1-day workshops and an 8-week dementia awareness course she has attended. Potential future training opportunities were also discussed. The managers’ approach is open and inclusive. She described the structure of staff meetings and minutes were provided of the most recent. The manager encourages staff to put forward ideas and this was confirmed during discussion with staff members. The home operates a quality assurance process that SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 17 seeks the views of residents, relatives and visitors to the home. A copy of the most recent assessment was provided. All staff receive regular supervision from the manager. This process is recorded and the records are kept locked in the managers’ office. The manager stated that residents are encouraged to take care of their own personal allowances and a s result only looks after small sums of money for 6 residents. All transactions are fully recorded. SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 4 4 3 x 3 3 x x SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 19 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. 1. Standard Regulation None 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 None Good Practice Recommendations SHIPDHAM MANOR I55 S27399 Shipdham Manor V231626 070605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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. 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