Inspection on 29/08/07 for Conroy Close (1)

This inspection was carried out on 29th August 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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) 20/09/06

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 Gill Sample Key Unannounced Inspection 29th August 2007 12:00 Conroy Close (1) DS0000007946.V335069.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.V335069.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.V335069.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.V335069.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. Date of last inspection 20th September 2006 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. The fees were £822 per week quoted by the registered manager on 19th September 2007. Information is available to people about the service in a Service User Guide to the home. This document is available in different formats. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: ● ● ● ● ● Reviewing information which has been received about the home since the last inspection. Written information provided by the manager prior to the inspection. Written surveys from relatives, carers and advocates of residents Written surveys from care staff working at the home. A visit to the home on 29th August 2007. The visit to the home lasted two hours. The inspector spoke to people who live at the home and staff on duty at the time. Records relating to people living there and the management activities of the home were inspected. Care practices and routines of the home were seen. This helped the inspector gain an insight into what life is like at 1 Conroy Close for the people who live there. Staff on duty at the care home assisted the inspector and were given verbal feedback at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The system for helping people with their medication is not protecting people from mistakes. The manager has been asked to change current practice so that residents receive their medication in a safe way. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 6 The records relating to staff recruitment, training and supervision needs to be available at any time so that they can be inspected. Some areas of care practice were seen which can be improved for the benefit of residents, such as when helping residents to eat a meal and when talking about residents. While residents now have a statement of terms and conditions about their care at the home, the service needs to ensure that an independent person assists the resident by signing agreement on their behalf. 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. The summary of this inspection report can be made available in other formats on request. Conroy Close (1) DS0000007946.V335069.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.V335069.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. People who use the service experience good quality outcomes in this area. They can be assured that their needs will be identified and recorded. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Care records showed comprehensive information about each person living at the home. The majority of residents have lived at the home for a number of years, and have complex needs. Information was on file showing people’s needs and how these were to be addressed. New assessments were being prepared to update information to put in place an ‘Essential Life Plan’ for each resident. One care record had a statement of terms and conditions covering the care element of people staying at the home. This had been signed by the manager. The service needs to demonstrate that the best interests of people living at the home are being served. A person who is independent of the service, such as a relative or advocate should be involved to ensure that the individual rights of residents are recognised. There was a copy of the individual tenancy agreements made with the landlord of the property covering the accommodation element of people staying at the home. Conroy Close (1) DS0000007946.V335069.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. People living at the home are encouraged to make their own choices about how they live their lives. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There were care planning documents in place for each person at the home. These contained information so that staff knew about the needs and wishes for each person living at the home. Reassessments were being made of people’s needs to prepare an ‘Essential Life Plan’ for individuals. Reviews of care required were documented on file. The majority of people living at the home have limited or no language skills. Staff on duty demonstrated that they are aware of people’s non verbal way of communicating and there were notes on care records to assist staff with less knowledge of people’s behaviour and what this told them about what the person wanted or how the person felt. Conroy Close (1) DS0000007946.V335069.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience adequate quality outcomes in this area. Daily life in the home and activities organised outside it meet residents’ needs though some practice needs to improve. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: One person said that they had settled into living at the home, having moved there from another area. They said that they went to a local Gateway Club and enjoyed painting and television. They said “I have visitors now and again. I generally go out for a coffee with them” A number of activities are available to people living at the home including some activities outside the home, such as swimming, local events, and visits to pubs and museums. Activities offered inside the home include music, films, art work and aromatherapy. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 11 Staff referred to female residents several times throughout the visit as “the girls”. Referring to adult residents in this way does not respect their age or individuality. People have a varied diet and there is an alternative should people not like the food offered. Lunch was being served in the sitting room when the inspection started. One staff member was helping two people to eat and was stood between them feeding each person alternately. This is not good practice because people are not receiving individual attention and were receiving their food from a person stood over them. Serving food in this way also means that the food itself is likely to get cold. When asked about people not eating at a table, staff said that residents were having an “easy day”. It was suggested that a chair be brought so that the staff member could attend to each person while sitting at the same level, but this suggestion was not taken up. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience adequate quality outcomes in this area. Daily life in the home and activities organised outside it meet residents’ needs. The administration of medication needs to be improved. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A requirement was made at the last inspection to review the medication system and for staff to receiving accredited training in medication. The requirement was made because the system staff were using meant that they were removing medication from a monitored dosage system into empty tablet bottles named for each person prior to taking the bottles downstairs to give people medication. Medication should be retained in its original packaging and not decanted into other containers so that there is less risk of error. At this inspection the way in which medication is administered was seen and has not changed since the last inspection. The manager made a risk assessment of medication practice in November 2006, which assessed that the system in use was safe. Since that time there has been a medication error when a member of staff administered the wrong medication to a resident. The way in which medication is given to people living at the home needs to be safe and the manager needs to address this issue. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 13 Care records seen showed good information about people’s personal and health care needs and how these were to be met. These showed when the person’s general practitioner had been called and why, and included any treatment or outcome of the visit. A number of support services can be involved to support the care given at the home including psychiatric nurses, occupational and speech therapists and diet advisers as part of the community team for people with learning disabilities. Staff confirmed that they had been trained in topics pertinent to the health care needs of people living at the home, such as epilepsy and dementia training. They also said they had been trained in the safe administration of medication, which is a Mencap course. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. They are able to raise a complaint about their service and are safeguarded from abuse by the awareness of staff. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure in place which is available in different formats. The home has not received any complaints since the last inspection. Staff use their knowledge and experience of people’s non verbal signs to identify if they are not happy with any aspect of their care. Information on how to complain is contained in the service user guide to the home and is available in different formats. Relatives written surveys said that they were aware of how to complain and who to speak to if they were unhappy about any aspect of their relative’s care. Staff spoken with were aware that there was a whistle blowing policy in place so that they could disclose poor or bad practice without fear of being identified or victimised. They said that they would report any suspected or alleged abuse to the manager or area manager and said that there was an on call system so that this could be done without delay. The system for ensuring that people’s money is handled properly was seen, which were up to date and had been checked regularly. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. They live in a home which is well maintained to a good standard of comfort and safety. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: All general areas of the home were seen, some bedrooms, the kitchen and laundry facilities. All areas were clean and well decorated. The style of the home is comfortable and decorated in keeping with the needs of the residents. There was no unpleasant odour. There is a system for the maintenance of the building and the system and equipment which it contains. There is outside secure garden space where people can sit. The home is clean and well maintained. Sitting areas are spacious and there are suitable aids and adaptations to support people with their independence and mobility. The majority of the accommodation is on the ground floor with level access so that it is suitable for people with mobility difficulties and wheelchair users. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 16 There are separate laundry facilities which are clean and self contained. Cross infection is minimised by the way soiled linen is dealt with and staff have been trained in good hygiene practices. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. Residents are receiving good care from a committed staff team who are well trained to meet their needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Information sent prior to the inspection confirmed the staffing hours per week at the home. Written surveys said that staff felt they had adequate numbers of staff to deal with the needs of residents. Staff receive a range of training to support them in doing their jobs and in meeting people’s needs. Staff on duty confirmed the training they had undertaken. Two of the twelve care staff have completed NVQ level 2 or above in care. Information sent prior to the visit confirmed the topics in which staff have been trained including mandatory health and safety topics and subjects pertinence to the age group of residents at the home, such as dementia awareness. Staffing records were not available for inspection because the manager who keeps the key to these records was not on duty. However, the last inspection report did not require any action to be taken in relation to the home’s Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 18 recruitment process. Records relating to staff recruitment must be available for inspection so that checks can be made to ensure that only suitable people are employed at the home. Staff each have a box file in which they keep documents relating to them, such as training materials. These included personal information and information on who to contact should there be an emergency involving the member of staff. This information was easily available to other members of staff and advice was given to consider the implications of data protection on these records so that any personal information about the member of staff is kept confidential. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience adequate quality outcomes in this area. People living at the home benefit from a well run home which is run in their best interests. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager Graham Jefferys was not on duty when the visit to the service was made. He has experience in managing the home and the care of the people who live there. Staff spoken with said that the atmosphere at the home was “very relaxed” and that the manager was “very approachable”. There is a clear management structure which is supported by the wider organisation. Staff have access to the area manager who visits the home regularly. Residents have the opportunity to influence the service and take part in wider forums to make suggestions about development of services. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 2 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 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 1 X X 3 X Version 5.2 Page 21 Conroy Close (1) DS0000007946.V335069.R01.S.doc Are there any outstanding requirements from the last inspection? Yes 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 Standard YA20 Regulation 13 Requirement The medication system must be reviewed and all staff involved the administration of medication must receive accredited training. This requirement is outstanding from the last inspection. Records relating to recruitment, training and supervision of staff must be available for inspection at all times so that checks can be made that staff are suitable appointed and monitored. Timescale for action 30/09/07 2 YA34 19 Schedule 2 29/08/07 3 YA39 26 Copies of the monthly visits 01/09/07 made by the provider on the conduct of the care home must be sent to the Commission’s York office. Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 22 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 YA5 Good Practice Recommendations Residents should have a contract or statement of terms and conditions relating to their care at the home. This should be signed by themselves or someone independent of the service such as a relative, advocate or legal representative so that residents can be sure that their best interests are being addressed. People living at the home should be addressed by the name they prefer. The way in which people are assisted to eat their meals should ensure that their dignity is respected. 2 3 YA16 YA17 Conroy Close (1) DS0000007946.V335069.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V335069.R01.S.doc Version 5.2 Page 24 - 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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