Shipley Manor Care Home

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. This was the first assessment of the service, and we rated the service good with 8 evidence categories in this assessment. There were sufficient staff to meet people’s needs, and staff had received all appropriate training to enable them to keep people safe. The provider had a safe recruitment process. We found the provider had an effective safeguarding process in place and the environment was safe and well maintained. However, the provider did not always have safe and effective systems in place for managing the safe administration of medicines.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives provided positive feedback with 1 relative informing us, “If there is a problem at all then I just need to speak with [registered manager] and I know that it will be sorted out straight away. [Registered manager] is excellent.”

Staff told us they were aware of how to report accidents and incidents and the registered manager demonstrated a clear understanding of the need to and how to learn lessons and review incidents.

The provider had safe systems in place to demonstrate evidence of lessons learnt. Accidents, incidents and safeguarding events were thoroughly reviewed, and action was taken to mitigate future risks. We also saw evidence of learning across the wider provider group and clear sharing of good practice.

People and relatives told us were pleased they had chosen this service. A relative told us, “[Relative] has only been here a week but the staff certainly have got to know them and are always letting me know what is happening with their care. I am really pleased they are at Shipley Manor.” One person who had recently been admitted into the service described staff as ‘kind and caring,’ and told us they were happy with the move.

Feedback from managers and leaders was positive showing a good understanding of the processes and systems in place to ensure safety during pre-assessments and referrals into the service. The registered manager demonstrated the ability to be person centred in their approach whilst embedding safe systems and practices.

We found the provider had an effective pre-assessment and referral process which utilised partnership working with external professionals for safe transitions into the service.

We found the provider had safe systems, processes and policies in place which were followed when admitting new people into the service. We reviewed one person who had been recently admitted into the service and they had all appropriate care plans and risk assessments in place timely reflective of their care needs and preferences.

People and relatives told us they felt safe and well looked after in the service. One person told us, “The staff always make sure that we are kept safe, all visitors have to be let in and must sign themselves in and out, so the staff know who is in the building.”

We saw how the registered manager understood and implemented their responsibilities to safeguard people from harm and abuse. Staff told us they felt confident in reporting any concerns and were comforted in knowing the registered manager would take appropriate action.

We observed people were supported safely by staff. We did not observe any concerns relating to people’s safety.

The provider had systems and processes in place to ensure people were protected from harm and abuse. We found some people had been subjected to necessary restrictions, but the provider did not have the appropriate best interest decisions or capacity assessments to accompany these. However, the registered manager was responsive to our findings and immediately took action to complete this paperwork. We were assured with the response and found no one had been placed at risk.

People were in receipt of safe care from staff and leaders who knew them and their needs well. People were involved in care planning and evaluating of their needs, and people told us they felt safe and well cared for in the service.

Feedback from management and staff showed effective and inclusive processes were embedded into risk management strategies.

We observed safe working practices throughout our onsite assessment. Where people required support with mobilising, we observed staff were confident and kind in their approach. Where people needed equipment, such as walking frames, these were personalised, in good condition and stored close to the person.

The provider had appropriate and effective systems in place to ensure premises and equipment safety checks and audits were completed consistently. This ensured all equipment was in good working order. Cleaning schedules were implemented and completed consistently showing good compliance with policies and procedures.

People and relatives were happy with the environment and facilities available. One person told us, “We can go out into the garden if we wish to. That area has a high safety fence so again, I feel safe out there.”

Staff feedback was overwhelmingly positive for the environment and how its maintained well. Staff comments included, “I think it’s a beautiful home and it smells lovely” and, “It’s a nice environment, safe, with nice wide corridors. Its not cluttered, it’s safe and clear.” Management and leaders told us they were aware of and ensured the service had appropriate equipment and facilities that were in good working order, whilst maintaining a homely environment for people.

We observed a spacious, clean, homely environment, where people had bedrooms which were personalised with their own belongings. People had all the appropriate equipment required to enable staff to meet their care needs.

The provider had appropriate and effective systems in place to ensure premises and equipment safety checks and audits were completed consistently. This ensured all equipment was in good working order. Cleaning schedules were implemented and completed consistently showing good compliance with policies and procedures.

People and relatives told us they felt there was enough staff to meet their needs and keep people safe. Some comments from relatives included, “There are always staff around so I feel that my [relative] is very well supported here."

Management were aware of their responsibilities for safe staffing levels, recruitment, training and development. The registered manager described all the processes used to manage, monitor and audit these systems. Staff told us they felt there were sufficient numbers of staff at all times and said they had received all the training they needed to provide safe care to people. Some comments included, “There is enough staff, potentially too many. We have the same number of staff on a weekend too. We never use agency; we just don’t need to.” Some staff told us, “We have had all the training we need online and in the home. [Registered manager] is also arranging for me to do the train the trainer course on moving and handling” and, “The training was great, I learnt things I did not know before.”

We observed there were enough staff to support people safely. The atmosphere throughout was calm and relaxed and staff responded promptly to people’s requests for support, and recognised when they needed reassurance.

Recruitment was managed safely, and all the required checks were in place. There was a clear and up to date recruitment policy in place which had been implemented when 1 staff member started employment prior to their second reference being received. There was a robust risk assessment in place which assessed the risk of them working in a shadowing capacity. Care rotas were reviewed which showed there was enough staff on shift and consideration had been given to the skills mix and ratio of males and females on shift. New staff received an induction when they started work and staff received the supervision and training they required to carry out their role safely.

People and relative feedback on the whole were positive and they told us they felt the service was clean and hygienic. However, 1 relative told us, “We have had to comment on the state of the bathroom, especially the toilet bowl. Things have improved now.”

Leaders were aware of their infection prevention and control requirements and ensured compliance in the service. Staff told us they had received infection prevention and control training and were provided with sufficient amounts of personal protective equipment (PPE). Comments included, “We have enough supplies of all PPE and I have been provided with my uniform too. At dinner time we put on hair nets, aprons and gloves as well. We use plate covers for the food. There are sufficient supplies of everything.”

We observed staff followed safe infection prevention and control practices and wore personal protective equipment when required. We were assured the provider had safe infection prevention and control systems and processes in place.

Cleaning schedules and infection prevention and control (IPC) audits were completed consistently and showed good compliance with IPC practices and policies. We were assured the provider had safe and effective systems in place to monitor compliance and were following current government guidance on visiting care homes.

We observed safe practices were followed by staff when administering medication to people. Staff took their time and adopted a person-centred approach to administering medication. People and relatives gave positive feedback for safe administration of medication, with one relative commenting, "My [relative] is given their medication when it is due.” However, we found evidence contradicting this feedback. We found medicines were not always ordered in a timely way, and therefore some people went without them.

Medicines policies and procedures were in place and staff and management confirmed they knew how to follow these. Staff told us they had completed medicines training. However, not all staff members had had their competency assessed in the last 12 months to ensure that they gave medicines safely, as recommended by the NICE guidance.

People’s medicines were stored securely and in an organised manner, including controlled drugs. Allergies were recorded on medicines records, and we found patches were applied and recorded correctly. This included the recording of the site of application and patch rotation, and daily patch checks were in place. Care plans reflected people’s current medicines and their associated risks. Information for medicines to be taken ‘when required’ was in place and with one exception the reason for giving the medicine and resulting outcome was recorded. Medicines audits were completed regularly and when medicines related issues were identified in the service, these were addressed quickly by staff. However, at the time of the assessment, some medicine related issues were found that had not been identified by the service's audits.