Inspection on 20/09/06 for Conroy Close (1)

This inspection was carried out on 20th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conroy Close (1) 17/09/08

Conroy Close (1) 29/08/07

Conroy Close (1) 14/02/06

Conroy Close (1) 11/10/05

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 Terry Downey Key Unannounced Inspection 20 September 2006 1:00pm th Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 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.V308532.R01.S.doc Version 5.2 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.V308532.R01.S.doc Version 5.2 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 www.mencap.org.uk Royal Mencap Society 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.V308532.R01.S.doc Version 5.2 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. 14th February 2006 Date of last inspection Brief Description of the Service: 1 Conroy Close is registered to provide residential, personal and social care, for six people with learning and physical disabilities, some of whom are over the age of 65 years. The home is dormer bungalow providing single bedroom accommodation, and suitable communal space. It is situated in a residential area close to local services and amenities. The premises are owned by New Era housing association and Mencap provides the care. The registered manager is Mr Graham Jeffreys. On the 20th September 2006 the fees were £825 per week. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of a review of the information held on the homes file since the previous inspection, information submitted by the home in the Pre Inspection Questionnaire, and a 4 hour unannounced site visit to the home on 20th September 2006. At the time of the site visit the manager Mr G Jeffreys was not available but there were four members of staff on duty, who assisted with the inspection, and were very helpful. It was difficult to communicate with the residents in the home at the time of the visit so some of the comments are based on observation. The site visit also included discussion with the staff, a check on the recommendations from the previous inspection, a tour of the premises and a check on the records kept by the home. Survey forms were completed by two health care professionals, and a GP, and all were very complimentary about the home, the staff and the care provided. The inspection showed that the residents were well cared for in a clean, well maintained, home. There is an experienced and committed staff team, and a manager, who work hard to improve the residents’ quality of life. What the service does well: The residents live in a clean, well-maintained home. Staff are kind and helpful and make an effort to provide the service the residents’ want. Residents are able to make choices in many areas of their lives. Examples included rising and retiring times, activities, clothes, and food. This ensures that they maintain some control. The residents are able to access the primary health care team and other professionals ensuring that their health care needs are met. A good choice of well prepared food, and drinks are available. This ensures that they receive a varied and nutritious diet. The home gets the views of the residents and others, about the service provided so as to make changes which improve the residents’ quality of life. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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.V308532.R01.S.doc Version 5.2 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.V308532.R01.S.doc Version 5.2 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): 2,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information required to choose a home which meets their needs . EVIDENCE: There haven’t been any recent admissions to the home requiring a full pre admission assessment. Three service users files examined showed that the needs of people who use the service are regularly reviewed and that every effort is made to ensure that service users are involved in determining how their needs and aspirations will be met. Written admission documentation was good and included a copy of the care management assessment. Very good information was available to staff to ensure they could meet the social, emotional and care needs of new residents. The residents did not have a written contract or terms and conditions of residence on their file but instead had a tenancy agreement with the owners of the property. This had been signed on their behalf by a manager but not read to the residents and was not relevant to their care needs in the home. This area needs to be addressed. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 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): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good care planning and risk assessments ensure that lifestyle needs of the residents are met EVIDENCE: Care plans contain the information required to assist the staff in meeting the individual needs of each resident. Two residents were case tracked and this indicated that their personal care needs were met appropriately. Assessments and care plans on the residents file were not dated or signed. The ones on the ‘working file’ used daily by the staff were signed but not by the residents or their representatives. Staff said that key workers draw up the plan with the resident but only the manager signs it. Staff had a very good understanding of the needs of the residents and were knowledgeable about their care plans and risk assessments. They were seen to be patient and kind when interacting with them and clearly provided individual care. Only one resident was able to communicate verbally and expressed high levels of satisfaction with the home and the care. Other residents were observed and were clearly happy and well cared for. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 10 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): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The social and recreational activities meet the residents’ needs and they eat a healthy and varied diet EVIDENCE: Each resident has an individual timetable designed to ensure that they are given the opportunity to take part in a variety of activities both within the home and the community, and staff are available to support them. The staff are constantly looking for new activities which will interest the residents and provide further stimulation and development. The residents enjoy going out and there are sufficient local amenities for them to enjoy. They all appreciate the new conservatory recently built onto the home. There was a lot of evidence in the daily records relevant to the activities they enjoyed. Menus were varied and well balanced. Mealtimes were said to be relaxed and social events. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 11 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): 18,19,20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents are well supported and their health care needs are met. EVIDENCE: There was a lot of evidence to demonstrate good liaison with the healthcare services and surveys returned from the Community Nurse, and the GP were further confirmation of this. The home’s medication procedure being used was not considered safe but the staff explained that they had used it for many years and were reluctant to change it. Medication was stored in the manager’s office on the first floor. Each resident was allocated a bottle with their name on it and their medication was dispensed into the bottle before being taken to the resident. This does not conform to the guidelines but the staff said this was how they had been trained. It transpired that they had only had ‘in house’ training and none had done the recognised accredited medication training. Despite this procedure being in long term use and the staff being reluctant to change it, there are risks attached to it and staff must be formally trained and use the recognised system. All records were well maintained and up to date. None of the residents self medicate. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 12 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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents are protected from abuse because staff are trained, work closely together and are well managed. EVIDENCE: A complaints procedure was available to all residents and this was included in the service user guide and can be made available in different formats. Staff had a good understanding of service users’ rights as citizens. The evidence indicated that residents are protected from abuse, the staff had done a training course in adult abuse and they were aware of the procedure. The recruitment procedure is good and ensures that only suitable people are employed in the home. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 13 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): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home enables residents to live in a safe, well-maintained and comfortable environment. EVIDENCE: The home was generally clean, well decorated and furnished. The hallway, lounge, kitchen, and some bedrooms had recently been redecorated as part of a rolling programme of decorations. The new conservatory was very popular and provided extra communal space for dining and activities. Residents had all personalised their bedrooms and some had purchased some of their own furniture. Specialist equipment was provided in the home and all was of good quality and serviced regularly. There was a good infection control policy to reduce the risk of infection and a programme of routine maintenance and decoration for the home which ensures that it is always a safe and comfortable place live Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from an experienced and committed staff team EVIDENCE: The rota showed that there were sufficient staff on duty and this was confirmed during the inspection. Staff were observed assisting the residents and also having time to spend talking to them. It was clear observing the interactions between the staff and the residents that there was a mutual respect and staff tried to help the residents to do things rather than do it for them. It was not possible to examine staff files because the manager was not available but discussion with the staff showed that a safe recruitment procedure is followed to ensure that only suitable people are employed. A good induction and training programme is then in place to ensure that staff are equipped to carry out their jobs well. A new member of staff was available during the inspection and confirmed that the manager and staff were very supportive and that the induction training was very helpful. This training includes the protection of vulnerable adults as well as the mandatory training to meet service users basic needs, such as manual handling and health and Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 15 safety. The mandatory training for all staff was not up to date and this needs to be addressed. Staff were clear about their role and knew what was expected from them. They said they worked well as a team and that the manager was very good, approachable, and supportive. . Staff had regular supervision and an annual appraisal which they said was clearly recorded. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 16 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): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good management arrangements ensure that the home is run to meet the needs of the residents EVIDENCE: The manager was not available on the day of the inspection but the home was clearly well organised and run and the staff were aware of their responsibilities. Issues of mandatory staff training and the medication procedure have been mentioned earlier. Staff explained that the manager dealt with all the administration, supervision and recruitment for the home. They were kept informed of relevant management issues, and they considered the manager to be very approachable and supportive. Survey forms mentioned ‘good communication’, ‘good organisation’, and ‘a well run home’. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 17 Staff considered that they were well supported by the management and that they worked well together as a team. The quality assurance systems in place are very effective and the manager is proactive in addressing quality issues within the home. The views of service users, staff members, relatives and professionals visiting the home are sought on how the service can be improved. The home has a Health and Safety policy and regular checks and staff training ensure that the home is a safe place to live and work. A senior manager visits the home monthly and talks to residents and staff, and completes a quality audit. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 18 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 Standard No Score 1 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 19 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. 1 2 Standard YA5 YA20 Regulation 5 13 Requirement The residents must have a contract / terms and conditions relating to the care in the home. The medication system must be reviewed and all staff involved the administration of medication must receive accredited training. Staff training in first aid, manual handling, food hygiene, and health and safety must be up date. Timescale for action 30/11/06 31/12/06 3 YA35 18 31/12/06 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 Refer to Standard YA6 Good Practice Recommendations All assessments should be signed and dated to ensure they are relevant and up to date. Care plans should be signed by the residents or appropriate representative to indicate their agreement to the care being provided. Conroy Close (1) DS0000007946.V308532.R01.S.doc Version 5.2 Page 20 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.V308532.R01.S.doc Version 5.2 Page 21 - 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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