Shipdham Manor

The following is CQC's published account of its assessment, published 20 August 2026. References to “we” mean CQC. It describes findings at that time.

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.