Inspection on 03/03/09 for Shipdham Manor

This inspection was carried out on 3rd March 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shipdham Manor 19/02/07

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Shipdham Manor Chapel Street Shipdham Thetford Norfolk IP25 7LB     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Shirley Christopher     Date: 0 3 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Shipdham Manor Chapel Street Shipdham Thetford Norfolk IP25 7LB 01362820939 01362822036 shipdhammanor@manorcourtcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Manorcourt Care (Norfolk) Ltd care home 31 Number of places (if applicable): Under 65 Over 65 0 31 dementia old age, not falling within any other category Additional conditions: 31 0 The maximum number of people who can be accommodated is: 31 The registered person may provide the following category of service only: Personal Care Only - Code PC to people of the following gender: Either whose primary care needs on admission to the home are within the following categories: Older persons not falling within any other category - Code OP Dementia - Code DE Date of last inspection Brief description of the care home Shipdham Manor provides residential care for thirty one elderly residents. The home was owned by ManorCourt Care (Norfolk) Ltd but now comes under the umbrella of Health care homes who bought the home last year. 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. Care Homes for Older People Page 4 of 26 Brief description of the care home 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 and is close to all local amenities. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, The Commission for Social Care inspection carried out an unannounced inspection on the 17 February 2009. We were at the home from 10:00 am until 5:00 pm. During this inspection we looked round the home, spoke to the manager, care staff, residents and visitors. We were invited to join residents for lunch and were able to observe care practises within the home. We did some case tracking and looked at some records. This is discussed in the relevant sections. Before the inspection we had written to the home and asked them to complete a self assessment form, known as a (AQAA), Annual quality assurance assessment. This was completed in good detail and returned to us before the inspection. We did not send out surveys for staff, residents and visitors but will do this before the next planned Care Homes for Older People Page 6 of 26 inspection. We looked at any information we had received from the home or about the home since the last visit. This included notifications, which the home are required to send to us. We have received no complaints or concerns about the service. We also considered the information in the last inspection report. There were no outstanding requirements. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 26 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that no resident moves in until their needs have been fully assessed and the home are confident that they can meet their needs. Evidence: The manager told us that the statement of purpose and service user guide have been recently updated. The documents are generic and are produced by Health Care Homes. The home manager has also introduced a service specific user guide about life in the home.The documents are made available to each resident and their family. Fees for the service range from 460.00 to 550.00 a week. Residents are kept informed about daily life in the home. There are 4 week menus in residents bedrooms and planned social activities are advertised on the notice board and through the quarterly newsletters. Care Homes for Older People Page 11 of 26 Evidence: The home has an admissions policy and encourage potential residents and their relatives to visit and spend time at the home. A full assessment is completed before the home decide if they are able to meet the residents needs. Other assessments are requested from social services and, or other health care agencies. We asked to see a pre admission assessment and this was satisfactory but not give us information about who was involved in the original assessment. The manager told us that the home won the 2008 health care homes award for staff training. Staff spoken to demonstrated that they had the necessary skills, experience and training to meet residents general and specialist needs. Examples of training are discussed in the relevant section, under staffing. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents receive health and personal care which appropriate to their assessed needs. Evidence: We spent time observing care practises, and talking to staff about how they meet residents needs. We looked at one care plan in depth and considered other sources of information, such as accident records, falls, medication and daily records. One person had been identified with specific mental health issues. The home had sourced specific help for this person. Risks had been evaluated. Before talking to residents we asked for a brief profile of a number of residents. Staff and the manager were able to give us an insightful account of their needs, and past histories. The daily records were well written and informative. They showed that staff acted upon changes to residents needs. The original assessment of need and the subsequent care plan were well written and gave sufficient information to enable care staff to meet residents needs in a consistent way. Residents preferred routines were recorded. The care plan had not been reviewed because the resident had been newly admitted. Other documentation Care Homes for Older People Page 13 of 26 Evidence: relating to falls, mental capacity nutrition and manual handling were in place. These documents had been reviewed. The home work in conjunction with other agencies including the occupational therapist and the Parkinsons nurse. The home had a plan relating to sexuality but this focused on personal appearance. This was discussed with the manager because we felt that information relating to relationships would be appropriate. Care records included life histories and the manager said this was something that the home were developing further and discuss with residents and relatives. We discussed the homes medication policy. Medicines are administered by trained, seniour staff. The primary care trust have carried out an audit this year. Only one resident has been assessed as competent to administer their own medication. There is a risk assessment in place and the resident has a locked facility in their bedroom. Staff audit their medication. The home completes regular medicine audits and the local pharmacist complete audits. Guidance for administering (prescribed when necessary) (PRN) medication was seen. Stock controls are completed weekly and a controlled drugs register was in place and controlled drugs were being recorded properly. The home had a homely remedies policy. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect their social, cultural and recreational needs to be met. The home take in to account residents life histories and develop life stories to assist staff in understanding and meeting residents needs, particularly where they may have impaired communication. Evidence: The home employs a person for 15 hours a week to organise, provide and evaluate activities to residents. The staff at the home are proactive in identifying and meeting the social needs of residents. Whilst we were at the home there were a number of visitors and the home clearly promoted an open and inclusive atmosphere. Visitors were invited to stay for lunch. A volunteer arrived in the afternoon to run a quiz with residents. Care staff stated that residents were encouraged to maintain links with the local community and were supported in visiting the doctor or the local shops. The home hosted a three course valentines ball three days before the inspection. The home was decorated in red hearts and residents and relatives stated how much they had enjoyed it. Photographs of residents engaging in activities were seen around the home. Care Homes for Older People Page 15 of 26 Evidence: The hairdresser was a frequent visitor to the home. Other examples of activities included, Music, (the banjo man,) art and craft, sing along, and crosswords. The home use alternative holistic therapies There is a day centre on site but this is accessed by a small number of people living in the community. The home has its own minibus. The home is registered for people with dementia. Staff receive training in this area. The home work with residents and relatives to obtain a life story and family tree. This enables staff to understand more easily the patterns of behaviour exhibited by residents with dementia. Rather than describing behaviour as challenging or the person wandering. They look to see if they can identify what the behaviour means to the person and how best to manage that behaviour. It was evident on the day that staff knew residents well and were able to demonstrate how they deal with behaviours in an appropriate way. Residents were treated with respect and the staff ensured that residents were encouraged to retain existing skills and to maintain their independence. Meal time was observed and food looked well balanced and appetising. Most of the residents ate in the main dining room and received adequate support from staff. Various aids, such as plate guards were used to facilitate residents independence. There is also an additional seating area away from the main dining room where a number of residents needing additional support eat. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has robust systems in place to safeguard residents. Residents can be confident that they are able to raise concerns/ complaints and these will be listened to and dealt with appropriately. Evidence: The home has not had any complaints since the last inspection. The manager records any concerns received and how she has acted upon these. Staff have received training in the protection of vulnerable adults and the home has suitable policies and procedures in place. The home has robust staff selection and recruitment polices but must ensure they follow these. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is accessible, safe and well maintained. Evidence: The home was fit for purpose and was maintained to a high standard of safety and cleanliness. Some areas of the home had been adapted to make them more accessible. For example the bathroom/toilet doors were painted in yellow to make them more identifiable. The manager was due to visit another home the following week to see how they had made the home more accessible for people with dementia, and see if there were any ideas which they could use. The home has ground and first floor accommodation and residents on the first floor have access to a large passenger lift. The stairs are gated. Communal areas are light, airy and well decorated. The home has a number of eating areas, one large dining room and a second smaller room where residents requiring more assistance eat with staff support. In the main lounge there is an old fashioned wedding dress which is a talking point for visitors and residents. There was a wish tree in the corner and photographs of residents joining in activities. The home has a room, which is reminiscent of a home as it would of been when residents were younger. It includes replicas of old radios and so forth. This is a quiet area where residents can sit and reflect. Care Homes for Older People Page 18 of 26 Evidence: The home is well maintained and some areas have been redecorated and repainted. There is a schedule to complete the whole building. Bedrooms are refurbished before a new resident moves in. The home has a safe, enclosed sensory garden. They have plans for a green house and a post box so residents can walk with a sense of purpose. Money for the sensory garden was donated and fundraising enables the home to add interest to the home and garden. One resident spoken to has a small garden plot and grows vegtables. This opportunity will be open to other residents. The home has good infection control procedures. There is a separate sluice and laundry room. There are designated domestic and laundry staff, who have had relevant training. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are met by well trained and suitably qualified staff. The home must ensure that they follow their own recruitment procedures to ensure residents are fully protected. Evidence: The home has a low staff turnover and the majority of staff have worked at the home for many years. The home do not use temporary staff to cover holidays or staff sickness. 80 percent of staff hold a national vocational certificate in care, (NVQ.) The home has a manager, a head of care and three senior staff. There are additional care staff who hold an NVQ qualification in care level 3 and are able to cover in the absence of a permanent senior staff. The manager is keen to develop staffs potential and does so by giving staff extra responsibilities. Examples include: one staff takes the lead on infection control, other staff are dignity champions. There is some set training coming up for end of life care/ dementia. The manager has completed training in the deprivation of liberty and care staff are doing training in the mental capacity act. The home employ a team of ancillary staff who were spoken to and they said they are appropriately supported and trained.The home has a house keeper who has an NVQ qualification in house keeping. Care Homes for Older People Page 20 of 26 Evidence: We spoke to the staff team and they were well informed about the residents needs. They had completed all the mandatory training and some specialist training including palliative care, dementia care and Parkinsons training. The staff team had worked at the home for many years from 6 to 17 years. Staffing numbers appeared appropriate for the needs of residents. The rota was inspected and the manager was reminded that staff surnames should be included and correction fluid must not be used. We looked at two staff files and these were unsatisfactory. One member of staff had only one satisfactory reference before they were employed. They had a POVA 1st but did not have a criminal records check in place. This was the same for the second file checked. The interview notes showed that gaps in employment had been discussed, but the application form did not include dates of employment. The person had two satisfactory references before they were employed. Staff induction in thorough and they use a book called passport to care which covers all the common induction standards. Before completing this workbook staff have five days induction in which they are shadowed by a senior member of staff. They have a three month induction period. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run and managed in the interest of residents. Evidence: The manager is suitably experienced and qualified. She has completed a degree in management and is now doing a course in dementia care at degree level. The manager stated she is well supported and her manager completes a formal audit of the service every month. A sample of records were seen and these were satisfactory. There are regional team meetings every six weeks. The manager is part of a quality team, which review and improve documentation. Care plans are currently being revised. The manager also meets with other managers from local homes, to share best practise. We looked at health and safety issues. The home was awarded the good food award in October of last year. The home had a recent health and safety inspection visit to follow Care Homes for Older People Page 22 of 26 Evidence: up some outstanding issues. The manager said these are being dealt with. The fire officer visited in the last year and raised an issue about a number of fire doors. The manager said they had dealt with this. At the main reception the home had the outcome of their annual quality assurance review. 21 people took part in this. The outcome was good. Regular meetings take place with residents, staff and visitors. The focus group looks at how the home can improve the service provided through direct involvement and consultation with the people using and who have an interest in the service. We looked at a sample of records and these were satisfactory. They included care records, medication records, maintenance records: gas, stair lift, emergency lighting,and fire records. We were unable to find any evidence of fire drills being carried out for staff. This must be done. The home has an annual plan which identifies strengths of the home and where they need to improve. The home audit falls and pressure ulcers. The manager told us that they hold focus groups, for which minutes were seen. The home hold personal finances for a number of residents. Two staff countersign any money handled and there is a clear audit trail, with receipts issued. Residents have a locked facility in their bedroom. Evidence of staff supervision was provided and staff felt appropriately supported by the manager. Staff have annual appraisals. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 38 23 All staff must be adequately trained in the appropriate procedures to be followed in the event of a fire. This is to ensure residents, staff and visitors are adequately protected. 30/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 25 of 26 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!