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Inspection Summary

Overall summary & rating


Updated 15 May 2018

At our last comprehensive inspection on 4 January 2017 we rated the service as requires improvement. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Responsive and Well-led to at least good.

Shipbourne House is a ‘care home’. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Shipbourne House accommodates up to 21 people, some of whom may be living with dementia, in one adapted building. At the time of our inspection there were 18 people living in the home.

There was a registered manager in post. 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 2008 and associated Regulations about how the service is run.

People were cared for by staff who had a good understanding of their care needs and personal preferences. Staff supported people to make choices about their care and people were supported to be as independent as possible. The home had been adapted to meet people’s needs and people could access all areas of the home with minimal support from staff.

People who received end of life care were cared for in a way that maintained their dignity and staff took steps to ensure that they remained pain free and comfortable.

Staff had time to talk with people and engage them in activities that people had chosen to do. There were a number of different activities for people to participate in as well as group-based activities provided by outside community organisations.

People and their relatives were involved in the planning of their care and people’s wishes and preferences were detailed in their care plans. People’s individual risks had been identified and steps taken to mitigate these. People’s care plans and risk assessments were reviewed regularly and updated when people’s care needs changed.

People’s medicines were stored, administered and managed in a safe way. Staffs’ competency in the safe management of medicines was assessed regularly. Monthly audits of people’s medicines were also undertaken.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. MCA assessments had been carried out and staff understood when they would have to make a decision in a person’s best interests.

Mealtimes were relaxed and people had a choice of meals. Where there were concerns about a people’s nutritional intake, timely referrals were made to the relevant healthcare professional. People were also supported to access healthcare professionals where there were concerns about their health or wellbeing.

There were no restrictions on when people could have visitors and there was plenty of space in the home where people could enjoy some privacy with their visitors.

Staff understood what constituted abuse and how they would report any concerns of abuse. Staff knew the different types of abuse and had received training in safeguarding. There were processes in place to ensure that staff appropriate to care for people were recruited. Appropriate background checks had been completed before staff commenced their employment.

Staff received training relevant to their role and received regular supervision with the registered manager.

Risks within the environment were assessed and monitored. Regular servicing of the utilities took place and moving and handling equipment was safety tested twice a year.

Accidents and incidents were documented clearly and these were analysed so any trends or patterns could be identified.

The home was clean throughout and staff understood their responsibilities in relation to infection

Inspection areas



Updated 15 May 2018

The service was safe.

People were cared for by staff who knew how to report any concerns of abuse and who had received training in safeguarding.

People�s individual risks and risks within the environment had been identified and planned for.

There were consistently enough staff to support people in a safe way and there were safe practices in place around the recruitment of staff.

Peoples medicines were administered, stored and managed in a safe way.

There were appropriate infection control measures in place and staff observed good practice in this area.

Accidents and incidents were fully documented and analysis of these incidents took place.



Updated 15 May 2018

The service was effective.

People�s health and wellbeing needs were assessed to ensure their needs could be met.

Staff received training relevant to their role as well as regular supervisions.

People were supported to maintain a healthy diet and prompt referrals were made if there were concerns about a person�s nutritional intake.

Staff worked with other organisations to ensure that people received coordinated care.

People were supported to access healthcare professionals.

The service had been adapted to meet the needs of the people living there.

Staff understood the Mental Capacity Act 2005 and there was clear documentation to show that people�s capacity had been assessed.



Updated 15 May 2018

The service was caring.

People were supported by staff who were caring and who had a good understanding of peoples care needs.

People and their families were involved in the planning of their care and their preferences and wishes were acknowledged.

People were cared for in a way that respected their privacy and maintained their dignity.



Updated 15 May 2018

The service was responsive.

People�s care plans and risk assessments were person centred and were reviewed and updated when people�s care needs changed.

People were supported to participate in a variety of activities.

Complaints were responded to fully and in a timely way.

People who were at the end of their life were cared for in a dignified way and supported to remain as pain free as possible.



Updated 15 May 2018

The service was well led.

The registered manager was visible and approachable and staff felt supported by them.

Staff morale within the team was good and staff enjoyed their work.

There were processes in place to gain feedback about the service from people, their relatives, staff and healthcare professionals.

People living in the service and staff attended regular meetings so they could have a say in how the service was run.

There were systems in place to monitor and assess the quality of service being delivered.

Training and resources were available to staff to drive improvement within the service.

Staff worked with other agencies and health care professionals in a collaborative and open way.