The Care Quality Commission
  • Care Home
  • Care home

Shipdham Manor

Overall: Good read more about inspection ratings

Chapel Street, Shipdham, Norfolk, IP25 7LB (01362) 820939

Provided and run by:
Healthcare Homes Group Limited

All Inspections

During an assessment under our new approach

About the service

The service is a care home. There were 38 people using the service at the time of the inspection.The service is based over 2 floors and has a large garden, communal areas and a dedicated room for activities.

Who the service is for

The service supports older people and people living with dementia.The service uses a household model of care. People live in small groups that share a kitchen, lounge and dining area. This helps create a familiar home environment where staff can support people in a more personal and flexible way.

This service was previously rated good. We carried out this assessment on 06 July 2026 to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.

Staffing levels were appropriate but the deployment of staff across other roles impacted on the delivery of the service: For example, planned social activities were not always delivered and hygiene standards were compromised due to a reduction in domestic hours. Concerns were also expressed about laundry. Staff sickness was having an impact on the service; however all the staff were permanent, many with years of experience and no agency staff were used. This helped ensure people received consistent care and support, and the registered manager was responsive to our feedback and deployed staff at the busier times of the day.

Minor issues were identified with medicines, but this did not impact on people’s safety, and this was immediately fed back to the provider to rectify. People were supported to see health professionals such as a doctor when they needed to. Staff were given the training they needed to support people safely and to eliminate risks as far as reasonably possible.

The provider ensured the environment was safe and well maintained. Staff informed us there were regular fire drills, and equipment was tested regularly to make sure it was safe. Fire risks were well managed. We raised concerns about deep cleaning at the service and cleaning of equipment such as wheelchairs which required improvement. However, this has since being addressed by the registered manager.

People were supported to join in activities in line with their needs to reduce the risks of social isolation. Despite staff’s best efforts social opportunities for people had been reduced due to staff sickness. However, we were assured that this was being addressed and the activities provided were thoughtful, well planned and stimulating. Activities included trips out, gender specific activities and therapeutic activities. We saw limited planned activity at the weekends or evening.

Mealtimes were generally well received with the permanent cook showing a good understanding of people’s dietary needs and show plates being used to support people in making appropriate food choices. Staff worked extremely hard to ensure people remained hydrated and we saw staff offering people regular and appropriate snacks. People who had previously been at risk of unplanned weight loss had gained weight recently.

People were supported to make decisions about their care and support, and their care was delivered in line with individual needs and preferences. Measures to reduce the risk of falls were in place, with the use of sensor mats and integral bed rails. Individual pendants might promote people’s safety when actively mobilising especially when in the garden.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the principles of the Mental Capacity Act 2005 (MCA)

Deprivation of Liberty Safeguards (DoLS) authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions they had choice, control and freedom over their lives.

Care was delivered by staff who demonstrated kind, caring attitudes towards people they were supporting, and people’s care plans reflected their needs. We identified that staff were not always keeping contemporaneous records of care delivered or food/fluid intake and were not always recording liquid food as fluid intake resulting in some fluid intake records showing under recommended fluid targets.We were informed staff were getting used to a new electronic records system. We saw in practice staff kept people well hydrated, but records did not always reflect this. We also found instances of low fluid intake recorded which did not record liquid foods people had consumed such as soup which would increase people’s recorded intake.

There was a positive culture in the home with staff expressing confidence in the management team and the support they provided. Staff felt valued and supported to be able to deliver care competently and be supported to develop their skills. Staff took pride in their work and demonstrated empathetic care including providing end of life support and treating people like loved ones.

The service used learning from feedback, incidents and reviews to make improvements and support ongoing development. Safeguarding concerns were appropriately managed.

Whilst we did not meet the registered manager whilst carrying out our assessment our request for information was quickly fulfilled and the senior management team supported the assessment.The registered manager has been extremely proactive in demonstrating the strengths of the service, their pride in the staff team and acting on any concerns we had. Staff were recognised for their contribution to care and were supported to go for staff promotions and receive awards for long service.

7 May 2019

During a routine inspection

About the service

Shipdham Manor is a residential care home providing personal care and accommodation in an adapted building over two floors. At the time of the inspection there were 41 people living within the home, many of whom were living with dementia.

People’s experience of using this service and what we found

People using the service and their relatives was unanimously complimentary about the care and life within Shipdham Manor. All the people we spoke with felt safe and recommended the service.

Staff were aware of how to safeguard people from potential abuse. Systems were in place to ensure risks were suitably assessed and mitigated for. The provider had robust recruitment procedures and had ample staff to ensure people felt safe and well cared for. The provider was thorough when reviewing incidents to ensure appropriate lessons were learnt.

People’s health and well-being were well supported and monitored. People received their medicines when they should and were enabled to access healthcare whenever required. People’s nutritional intake was well supported. Staff were well trained and understood the individual care needs and preferences of people living in the service. The home compromised of an old manor house with a purpose-built extension. It was well adapted and dementia friendly, with a variety of accessible communal spaces and garden. There were some aspects of the home that required updating but the home already had an action plan to address these issues.

All the people we spoke with were very complimentary about the kindness of staff. We observed warm and compassionate care which demonstrated strong relationships and understanding of people’s needs and preferences. People’s privacy and independence were promoted. Staff had time to spend with people and were not rushed when providing support. People were regularly asked for feedback on the care and support they received. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People had individualised care plans which supported greater understanding of the person’s life and preferences. There was a wide range of activities which promoted health and well-being. These included regular sessions in exercise, arts and crafts, music, pet therapies and outings. The provider was pro-active in seeking and responding to any concerns or complaints people may have had about the service. The provider was accredited with a nationally recognised scheme which promoted quality end of life care. People had been consulted regarding their end of life care wishes when appropriate.

The feedback from both staff and people using the service regarding the registered manager was unanimously positive. The registered manager was seen to be accessible, compassionate and knowledgeable. There were good quality assurance systems in place and people were regularly consulted on the quality of care provided. Staff were provided with appropriate support and career progression encouraged. The team spirit was strong and staff retention was consequently high. The provider was proactive in encouraging best practice and considering service development.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was ‘Good’ (published 31 October 2016)

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

10 October 2016

During a routine inspection

This inspection was unannounced and took place on 10 October 2016.

Shipdham Manor is a service that provides accommodation and personal care for up to 42 people. On the day of our inspection, there were 41 people living within the home, most of whom were living with dementia.

There was a registered manager employed at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the home is run.

People were cared for by kind and caring staff who listened to people, made them feel valued and treated them as individuals. There were enough well trained staff to provide people with the care they needed.

The equipment that people used had been well maintained and people received their medicines when they needed them. Risks to people’s safety had been assessed and actions taken to reduce any risks that had been identified.

People had access to plenty of food and drink to meet their individual needs. Advice from other healthcare professionals was sought and acted upon when any concerns about people’s health had been identified.

The staff requested people’s consent before they provided them with care. Where people were not able to give consent, the staff made sure that any decisions they made on their behalf were taken in the person’s best interests.

There was an open culture where people, relatives and the staff felt able to raise concerns without any hesitation. The registered manager and senior staff demonstrated good leadership and the staff worked well as a team to deliver good quality care.

Systems were in place to make sure that the care being provided was safe and of good quality. The registered manager and the staff were pro-active in trying to improve the quality of care that was being provided to the people who lived at Shipdham Manor.

16 July 2013

During a routine inspection

We spoke with people who lived at the home and relatives who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to.

Our observations showed us that staff members were responsive to the needs of people and that they were given the support and attention they needed. We saw that people had a positive experience of being included in conversations, decision making and activities.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted and protected.

People spoken with and their relatives told us that people were provided with the care and support they needed and that staff were excellent and very kind.

Medication was administered, recorded and stored accurately and safely.

Staff members were well led, trained and supported to provide an appropriate standard of care and support through effective management, supervision and staff team meetings.

Quality audits were being carried out to ensure the views of people were gathered on the quality of the service provided, that people were safe and that policies and procedures were being followed.

3 October 2012

During a routine inspection

We spoke with four people who lived in the home. People told us that their needs were met and that they were consulted about the care and support that they were provided with. People were complimentary about the staff who cared for them and told us that they always treated them with respect and that their privacy was respected. They told us that occasionally they had to wait a short while for help because staff members were very busy. They also told us that activities were provided and that they could choose if they took part. They said that they were provided with good quality meals and that the environment was comfortable and clean.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not comment. We observed two groups, one of ten and one of six people for thirty-five minutes. We saw that when staff members were with people that they used explanation and negotiation when working with the person and used reassurance and praise appropriately. We noted that each person had their opinions respected and were included in the general conversations that occurred. We saw that staff responded well to the needs of people, gave them individual attention, listened and spoke to them in a positive manner and encouraged them to make choices.

21 December 2011

During a routine inspection

We spoke with a number of people whose home is Shipdham Manor. They told us how they feel part of a big community and that they are treated respectfully and with dignity.

We were told how they were listened to, how they can express there view and know that any concerns will be acted upon. 'I feel well supported and safe.'

One person told us that the staff team were supported by a very good and involved manager. They said the staff team were like one family. 'They know what they are doing as they all work well together and support each other'.

The people we spoke with, which included family members, were full of praise for the care provided by this home. Comments such as 'You would not find a better home anywhere' and 'This place is excellent' were just some numerous positive comments'.

Another person who lives in this home said that when they first arrived they did not like their room and did not want to stay. They told us that after a while the care support, staff team and management were so good that they now would not live anywhere else.