Shipdham Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Overall, the environment and equipment were well maintained with audits and clear scheduling for maintenance. However, areas such as a kitchen on one of the units was not clean. Wheelchairs needed cleaning. Whilst there was a programme of refurbishment, we identify a carpet needed replacing and odours in certain parts of the building.The registered manager immediately held a meeting with the relevant department to discuss our concerns and ensured longer domestic cover across the day and shared the environmental refurbishment plan which was robust. Most floor surfaces had been replaced and refurbishment plans included replacing carpets.

We recommended the sensory objects on the wall were considered in terms of risk of people ingesting foreign objects. Weadvised that signs advising people of a change of floor gradient are replaced following their recent removal whilst parts of the home were being redecorated.

The provider did not always make sure there were enough qualified,skilled and experienced staff who worked effectively together and were deployed appropriately.

We had concerns about key aspects of the service delivery and how these were impacted by staffing levels but found no direct impact on people’s care. Staff retention was good and the service had regular staff who were familiar with people’s needs. However, the deployment of staff across the day was impacting on activities, night care, when there was reduced staffing, laundry and cleaning tasks. Night staffing levels could fluctuate which had an impact on cleaning schedules but there was no evidence people’s care needs were not met. All staff said management were supportive and people’s care was prioritised and it was clear social aspects of people’s care was given priority.The provider told us staffing levels would be reviewed and made some amendments to the cleaning and laundry rota

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.