Inspection on 11/10/05 for Conroy Close (1)

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Conroy Close (1) 17/09/08

Conroy Close (1) 29/08/07

Conroy Close (1) 20/09/06

Conroy Close (1) 14/02/06

Conroy Close (1) 15/03/05

Conroy Close (1) 20/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Conroy Close (1) 1 Conroy Close Easingwold North Yorkshire YO61 3NS Lead Inspector Kate Shackleton Unannounced Inspection 11th October 2005 Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Conroy Close (1) Address 1 Conroy Close Easingwold North Yorkshire YO61 3NS 01347 821700 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) h1m001jeffery@mencap.org Royal Mencap (Housing & Support Services) Mr Graham Howard Jefferys Care Home 6 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (3) of places Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration is for 6 persons with a learning disability who may also have a physical disability, three of whom are over 65. 15th March 2005 Date of last inspection Brief Description of the Service: 1 Conroy Close is a care home providing personal care and accommodation for six people with learning and physical disabilities, some of whom are over the age of 65 years. The majority of service users have high dependency needs. The premises are owned by a housing association and the care is provided by Mencap The house is a dormer bungalow with two service users bedrooms on the first floor and the other four bedrooms are all on ground floor. The home is situated in a cul-de-sac close to local amenities. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. The focus was on a number of key standards together with those subject to a recommendation at the previous inspection. The inspector looked around some of the building and a number of records were inspected. Due to communication difficulties only one service user was spoken to in private. Discussions were held with two members of staff and the manager of the home. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that the way in which the support required for one service user relating to meal times is written in the care plan does not imply the withholding of food. Risk assessments must be properly complete to minimise the risk of injury to service users and staff. The formal supervision and annual appraisal of staff must improve so that proper monitoring takes place. The manager must make sure that the policies and procedures provided are followed in full. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 6 Every effort must be made to help the manager achieved the NVQ level 4 qualification by the end of the year. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Regular reviews of service users needs take place to ensure that the service can continue to meet the needs of individuals. EVIDENCE: The group of people who live in the house have lived here for many years and therefore there are no recent admissions requiring a pre-admission full assessment. There is however ample evidence in the service user files examined that care needs are regularly reviewed and that people who use the service are supported to live fulfilling lives. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Service users have comprehensive individual care plans, and are fully consulted and given choice about how their needs are met. Poor risk assessments place service users at risk of injury. EVIDENCE: The home operates a key worker scheme and each service user has an individual care plan. The plans identify health, personal and social care needs and state clearly how these are to be met. The plans include information about the service user’s preferred daily living routines and their interests and hobbies. Because some service users have significant communication difficulties staff have to use their knowledge and observation of service users in making decisions on their behalf. Staff are aware of service users rights to make decisions and choices and work hard to include service users in all discussions about how they live their lives. Plans are reviewed at least annually or as changing needs dictate. One service user described living at the home as ”very nice” Risk assessments are completed with a view to minimising the risk of harm or injury whilst still ensuring that service users are enabled to be as independent Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 10 as possible. The three service user files examined showed that one risk assessment had only been reviewed once in three years and the remaining two were incomplete in key aspects. The provider’s policy and procedure on risk assessment provides clear guidance on how to complete the document and the manager has received training. The poor content of the risk assessment has the potential to place service users at risk. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Service users enjoy a fulfilling lifestyle both in and outside of the home and links with the local and wider community promote social opportunities. EVIDENCE: Staff use their knowledge and understanding of service users to determine the types of activities that they might enjoy. Files include a range of leisure activities that service users access and on the day of this inspection two staff were taking service users on a shopping trip to York. Good use is made of local services and amenities. Daily routines are flexible and worked around people’s individual needs. Staff training includes the provider’s philosophy of care, which promotes the importance of respecting and protecting service users. Staff spoken to confirmed that they had sufficient time to engage in leisure activities with service users. Service users are encouraged to maintain family contact where appropriate and some family members visit the house. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 12 Menus are developed in line with people’s likes and dislikes and some aspects of healthy eating are taken into account. Service users are involved with menu planning. The way in which the support of one service user at mealtime is written is questionable and open to misinterpretation. It suggests that in order to encourage the individual’s independence in eating un-aided that staff have not to assist with feeding and after a period of time to remove the food and reoffer at a later time. The manager gave assurances that the withholding of food is never used as a behaviour modification technique and agreed to revise the written support to ensure that the desire to promote independence never overrides an individual’s right to proper nourishment. In situations where there are difficulties in supporting service users with eating and drinking and there is a risk of people not receiving proper nourishment a case review should be held the outcome of which should be documented in the service user plan. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The personal and healthcare needs of the service users are met with evidence of good liaison between the home and other agencies to enable service users to have access to all specialist healthcare services. EVIDENCE: Staff aim to promote the independence of the service users. Service users preferences as to how they are supported are recorded within their individual care plan. Each service user has a GP and access to chiropody, dental, optical and audiology services when required. Referrals to specialist services are made as appropriate. One service user was receiving ongoing support from the community Learning Disability team and the community nurse is currently visiting one service user. Direct observation showed that staff interaction with service users was friendly and helpful. Proper medication procedures are in place for the safe administration, recording, storage and return of unused medicines. The community pharmacist visits annually to check that the systems in place remain satisfactory. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users are protected from abuse through appropriate policies, procedures and staff training. EVIDENCE: There is a clear user- friendly complaints procedure, which can be made available on audiotape. The procedure is also contained in the service user guide. No complaints have been made about the home. There are robust procedures for responding to suspicions or evidence of abuse or neglect including whistle blowing. Staff receive training in abuse awareness In order to minimise the risk of financial abuse, sound accounting and recording systems are in place for all financial transactions completed on behalf of service users. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is clean, well-furnished and decorated providing service users with a very comfortable home. EVIDENCE: All service users have their own bedroom, which is furnished and decorated in a way that they like. The home is bright and feels spacious. It resembles any ordinary domestic household and is ideally situated to access all the local amenities in Easingwold. The premises are owned by a housing association, which has a planned maintenance programme. On the day of this visit the outside of the house was being painted and plans are in place to redecorate the hall and lounge in January 2006. Work required to improve fire safety following a fire service inspection has been completed. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 The monitoring and formal support of staff needs to improve to ensure that staff remain competent to deliver a good service EVIDENCE: Of the eleven staff employed at the home no one has a National Vocational Qualification. Currently one staff member has almost completed level 2 and intends to go on to do level 3. One staff member is doing level 3 and the manager says that a further three staff are to enrol on level 3 before the end of the year. It is anticipated that by the end of this year two staff will have achieved their NVQ award. The manager says that the low number of NVQ qualified staff is due in part to two staff who had achieved the award recently leaving and a general reluctance amongst remaining staff some of whom are nearing retirement to undertake training. The two members of staff spoken to were undertaking NVQ training and said that the training they receive is good and provides them with the knowledge and skills to carry out their duties competently. The home has robust recruitment policies and procedures and staff are properly vetted and interviewed before they are offered a job minimising the risk of employing unsuitable people. All staff are recruited subject to a probationary period and have to complete induction and foundation training. Training needs are identified and a training programme developed. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 17 Staff files examined showed that regular recorded supervision is not taking place. One file seen showed that a new starter in June 05 had a recorded supervision meeting in July 05 and none since. Two other staff files had no record of supervision meetings. The manager explained that he found it difficult to find the time to do them with all the other demands that are placed on him especially the need to be a “hands on” carer as well as the manager. Staff spoken to say that they felt very well supported by their manager and that he was accessible to them. Staff do not receive an annual appraisal to review performance against job description and agree career development plans. There are only two recorded team meetings this year. The manager does however work alongside staff and is able to observe their practice. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,and 42 Some aspects of the management of the home are not satisfactory. This has the potential to adversely affect service delivery. Systems are in place to ensure the safety of service users. EVIDENCE: The manager started his NVQ level 4 approximately eighteen months ago. He has experienced some difficulties in completing the course due in part to poor support from the initial course provider which has now been resolved and also insufficient time due to his work commitments. He is hoping to complete the course before the end of the year. A number of the provider’s policies and procedures are not being followed namely; proper risk assessments, regular recorded staff supervision and staff annual appraisal. There is an internal Quality Assurance system, which aims to measure success in achieving the aims, objectives and statement of purpose of the home. Due Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 19 to communication difficulties it is not possible for service users to complete satisfaction surveys. There is a range of health and safety checks carried out and staff training provided to ensure that the health and safety of service users and staff is promoted. Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x X 3 x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conroy Close (1) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 3 x DS0000007946.V253054.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 9 36 Good Practice Recommendations The risk assessment form should be completed in full with sufficient information to identify the risk and how any remaining risk has to be managed. Staff should have regular recorded supervision meetings at least six times a year with their manager in addition to regular contact on day to day practice. Staff should have annual appraisal with their line manager. Arrangements should be made to enable the registered manager to complete his NVQ level4 qualification by December 31st 2005 The registered manager in line with his overall responsibilities should ensure that the policies and procedures provided by Mencap are fully implemented. 3 4 37 37 Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Conroy Close (1) DS0000007946.V253054.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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