Inspection on 19/02/07 for Shipdham Manor

This inspection was carried out on 19th February 2007.

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 15/11/05

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 Maggie Prettyman Unannounced Inspection 19th February 2007 09:45a 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.V331067.R02.S.doc Version 5.2 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.V331067.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipdham Manor Address Chapel Street Shipdham Thetford Norfolk IP25 7LB 01362 820939 01362 822036 shipdhammanor@manorcourtcare.co.uk www.manorcourtcare.co.uk Manorcourt Care (Norfolk) Ltd 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) Care Home 31 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (31) of places Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 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 Current range of weekly fees is £325 - £480. The Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: What has improved since the last inspection? The new manager has made many changes and improvements since the last inspection. • Care plans are being reviewed and developed • Nutritional screening has been improved • Audits of pressure areas are now in place • The medication system and storage of medicines has been improved • Focus groups of service users and their representatives are in place • A newsletter is produced twice yearly • Individual annual review meetings with service users and their relatives are in place • A quality audit has been conducted Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 6 • • • • Redecoration of the upper floor and refurbishment of the main lounge has been completed Menus have been changed to reflect service user wishes The managers office has been relocated to a central location Supervision systems for staff have been improved. 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. The summary of this inspection report can be made available in other formats on request. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 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.V331067.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6 No service user moves into the home without having their needs assessed and been assured that these will be met. Each service user has a written contract with the home. Service users coming for short stays are helped to maintain their independence. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 9 EVIDENCE: Examination of service user files and records demonstrated that a needs assessment is conducted for service users prior to their being admitted to the home. Service user files also demonstrated that signed contracts are in place. Some extra services are charged for and these should be detailed in the service user guide. It is recommended that services requiring an extra charge should be detailed in information given to service users prior to admission. Observation of a service user coming for respite care on the day of inspection demonstrated that every effort is made to retain that persons’ independence so that they can return home at the end of their stay. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Service users Service users Service users medicines Service users needs are set out in an individual plan of care health care needs are fully met are protected by the homes procedures for dealing with are treated with respect and their privacy is upheld. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of service user files demonstrated that individual plans of care are in place for all service users. The new manager is in the process of updating and renewing all care plans in the home. Handover notes were found in a separate book. It is recommended that duplicate handover notes be discontinued. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 11 Evidence in service user files showed that care is taken to support service users health care needs. Risk assessment of pressure areas is undertaken and a new audit system is being implemented. Nutritional screening processes have been updated and improved. The home does not have its own set of scales. It is recommended that scales be purchased to facilitate the nutritional screening process. Pre inspection feedback from a GP and health care professional, as well as discussion with a visiting GP during the inspection demonstrated that health care given by the home is consistently good. Inspection of the medication system and records showed that medicines are safely and carefully administered. Records were up to date and complete. The system and storage of medication has been improved since the last inspection. Feedback from pre inspection questionnaires and observations ad discussion with service users on the day of inspection demonstrated that service users are treated with respect and dignity. Double rooms have privacy screening, mail is handed to service users unopened and clothes are individually labelled and carefully laundered. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 The lifestyle of the home meets the needs of service users. Service users retain contact with their family, friends and community. Service users exercise choice and control in their lives. A good appealing diet is provided in consultation with service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 13 EVIDENCE: The home has a wide range of activities and leisure opportunities available to service users, and the new manager is developing its dementia care support services. Prior to the inspection, comment cards had raised concerns about more service users with dementia care needs being accommodated by the home. The home is aware of these issues and is working to expand the training of staff and to improve the environment to support people with these needs. On the day of inspection the homes routines were seen to be flexible and accommodating. Service users files demonstrated that some life history details are recorded. It is recommended that more detailed life histories be recorded to further facilitate the home meeting the lifestyle needs of service users. Discussion on the day of inspection as well as details of previous events displayed on notice boards showed that good community contact is maintained by the home. The location of the home in the middle of the village facilitates involvement in community activities and groups. The new manager is taking positive steps to fully involve service users in the running and direction of the home. Individual meetings, focus groups and annual surveys are now in place. Plans are being made to involve service users in the staff recruitment process. Information about external advocates is clearly displayed in the hall area. The kitchen in the home was found to be clean, tidy and well organised. Catering staff consult with service users when planning menus. Menus were found to be varied and wholesome with home cooked food and choice offered. Soft diets are carefully prepared, and emphasis is placed on such food being attractively presented. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Complaints are listened to and action is taken Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes’ complaints procedure is clearly displayed in the hall. Evidence of a complaint received with appropriate action taken was seen. The manager has instituted new complaint forms and documentation. It is recommended that a record of minor complaints, comments and compliments is kept and audited to identify any patterns and trends that may inform service development. Adult protection training forms part of the mandatory induction training provided to all staff by the home. Records of this training were seen. Staff trained include domestic and catering staff. All staff are also given training in dementia care including techniques of intervention and de-escalation. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26 Service users live in a safe, well-maintained environment. The home is clean pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises showed that the home is safe and well maintained. The upper floor has been redecorated with new carpets laid. The garden is clear and tidy, with an area cordoned off for building work to take place shortly when two new rooms will be provided, and the garden re-laid to make it more accessible to service users. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 16 During the inspection it was noted that two bathrooms lacked homely decoration. It is recommended that the home make all bathing areas comfortable and homely so that service users can fully enjoy their bathing time. All areas of the home were found to be clean, pleasant and hygienic. The laundry is well organised and secured as bleach based products are used. Evidence was seen that the home provides infection control training for all staff. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 The numbers and skill mix of staff meets Service users needs. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment practice. Staff are trained and competent to do their jobs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of the rota and discussion with the manager demonstrated that the home has enough staff to meet its needs. Sickness absence is covered by a flexible team of permanent staff. Agency staff are not used. Peak times have additional staff on duty. The home is doing well in achieving NVQ qualification for its staff; all staff have either achieved or are in the process of achieving NVQ qualification. The home is to be commended for this achievement. Inspection of staff records demonstrated that staff are routinely vetted prior to commencing work at the home. A copy of the CSCI document “Safe and Sound” was left with the manager to offer suggestions of further good practice that could be implemented by the home. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 18 Discussion with the manager demonstrated that the home puts great emphasis on the training and development of its staff. The home keeps up to date records of all training given to staff. The manager is in the process of improving the way that these records are audited. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33, 35, 36 and 38 A competent and experienced manager is running the home. A system of quality assurance is being implemented. Service users financial interests are safeguarded. The health, safety and welfare of service users is promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 20 EVIDENCE: The new manager demonstrated confidence and competence throughout the inspection. She has relocated the manager’s office to a central area to improve access and communication. Evidence of much change and development of the home since her appointment was seen, but she has yet to undertake her registered managers interview with the commission. It is recommended that the manager complete her registration with the commission. A quality assurance survey has been undertaken with service users and staff, with actions implemented as a result. The manager has completed an annual development plan for the home. A good start has been made in instituting quality audit in key areas such as nutrition and pressure area care. Feedback from quality assurance surveys and focus groups with service users and their representatives has generated change and development in the practices of the home. Monies held on behalf of service users `were checked and found to be regularly audited. One minor discrepancy was found. Records seen demonstrated that he manager has implemented a regular documented and audited system of supervision. Supervision agreements are yet to b e put in place. Records demonstrated that mandatory training is given to all staff and is regularly updated. Hazardous substances were found to be safely stored and supervised while in use. A tour of the premises found it to be tidy and free of trip and other hazards. Risk assessments are conducted and accidents are reported as necessary. It is recommended that falls and accidents be audited by the home to identify any patterns and trends. Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 21 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 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 3 X 3 X 3 3 X 3 Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 2 3 4 5 6 7 8 Refer to Standard OP2 OP7 OP8 OP12 OP16 OP21 OP31 OP38 Good Practice Recommendations Services that do not form part of the weekly charge should be itemised in the information given to service users. Duplicate handover notes should be discontinued. A set of scales should be purchased for the home. The home should seek more detailed life histories for service users. Patterns and trends of complaints, comments and suggestions should be audited by the home. Bathrooms should be made more homely and comfortable The manager should complete her registered managers interview with the commission. Falls and accidents should be audited to identify patterns and trends Shipdham Manor DS0000027399.V331067.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V331067.R02.S.doc Version 5.2 Page 24 - 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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