CARE HOME ADULTS 18-65
Conroy Close (2) 2 Conroy Close Easingwold North Yorkshire YO61 3NS Lead Inspector
Mrs Irene Ward Unannounced Inspection 14th February 2006 12:30 Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Conroy Close (2) Address 2 Conroy Close Easingwold North Yorkshire YO61 3NS 01347 821488 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) h1002@mencap.org.uk www.mencap.org.uk Royal Mencap Society Mrs Susan Palmer Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include up to 6 (LD) and up to 6(LD(E)) up to a maximum of 6 Service Users. 11th October 2005 Date of last inspection Brief Description of the Service: 2 Conroy Close is a care home providing personal and social care and accommodation for six people with learning and physical disabilities, some of whom are over the age of 65 years. The premises are owned by a housing association and Mencap provides the care. The house is a single storey bungalow situated close to local amenities. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 14 February 2006, which started at 12.30 until 2.30. Four service users were in at the time. The registered manager was not on duty at the time of inspection. A tour of the home was carried out which included two of the service users private accommodation. A selection of records was looked at and time was spent observing activity in the home. Due to communication difficulties only one service user was spoken to in private. The focus of the inspection was a number of key standards. There were also discussions with staff members on duty. What the service does well: What has improved since the last inspection?
As part of their Quality Assurance process and a recommendation made at the last inspection, the home is surveying and seeking views about the service from a range of people. Such as friends, relatives, and health and social care professionals. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 6 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 (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 (2) DS0000007947.V280355.R01.S.doc Version 5.1 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): 1 and 5 Service users have all been given a written contract. EVIDENCE: One new service user has been admitted into the home temporarily from 1 Conroy Close. No changes have been made to the Statement of Purpose or the Service User Guide. Terms and Conditions of residency or tenancy agreements are given to service users and a copy held on their file. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 Service users are supported in making decisions about their personal lives. EVIDENCE: There are comprehensive plans of care in place. Two service users support plans were inspected. These had been regularly reviewed. The format for support plans are to be changed by the organisation and Person Centred Planning is to be introduced. The plans contained details of the service users daily living routines, personal care needs, interests and dietary needs. Service users are involved where possible in planning their daily activities. Risk assessments have been completed on all areas of daily living and the assessments are held on each service users file. Staff was observed as being supportive and courteous at all times. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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): 11 and 14 Service users access appropriate leisure activities. EVIDENCE: Service users support plans detailed the types of activities that they may enjoy. Plans included a range of activities that service users access such as going to the Gateway Club, trips to the coast and going to the Boot shop. The Boot shop is where people with a learning disability have the opportunity to further skills such as cooking, sports, music, dancing, living skills and women’s health. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 and 21 Service users health and personal care needs are well met. EVIDENCE: Care plans inspected indicated that the service users had contributed to them where possible and in agreement how their personal support needs were to be met. One service user confirmed that arrangements were satisfactory and that a flexible routine enabled them to choose when to go to bed and get up in the morning. Arrangements are in place for service users to access health and social care professionals. The York District Hospital is accessed for any emergencies via the A & E department. Outpatient appointments are also made. In discussions held with staff on duty regarding the age range of service users. It was clear that he was aware of the needs of service users because of the ageing process. Discussions were also held in respect dementia and of death and dying. Staff had experienced several deaths over the last three years. Staff were also able to demonstrate their knowledge, skill and understanding of how the changing needs of service users with deteriorating conditions such as dementia are supported. The organisations policy and procedures regarding the death of a service user is in place.
Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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 Service users complaints are listened to. EVIDENCE: The organisations complaints policy and procedures are in place. The complaints policy is clear and user friendly. One service user confirmed that if they had a concern that it would be dealt with by the registered manager. There had been no complaints received by either the home or the Commission For Social Care Inspection. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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): 24,25,27 and 30 The environment of the home is maintained to a good standard and provides service users with a clean and homely place in which to live, although there are not sufficient bathing facilities for service users. EVIDENCE: One service user showed me their bedroom. They stated that they were very happy with their accommodation and all aspects of their home. Two bedrooms were inspected all bedrooms had been furnished to a good standard. Service users have personalised their own bedrooms. All communal areas of the home were warm, well lit, ventilated and clean. The main corridors have been decorated with colours that people with the onset of dementia recognise. The home does have sufficient bathrooms and toilets that were clean and well maintained. However service users do not use one bathroom, as it does not have an assisted bath. All service users use one adapted bathroom, which causes some difficulties as to when and how often people can bathe. The registered provider must give this matter urgent attention, as this does impact on the quality of life for service users living at the home. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 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): 31 and 36 Service users benefit sufficient numbers of staff that are well informed. EVIDENCE: The staff duty roster was inspected. This reflected four staff on duty in the morning. Two staff had gone out shopping with one service user. There is one waking nigh staff and one sleeping in staff on duty each night. Staff confirmed that they receive regular supervision. Supervision records were not inspected on this occasion, as the manager was not on duty. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 15 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): 42 Service users’ health safety and welfare are promoted and protected. EVIDENCE: Throughout the afternoon from discussions held with one service user and staff and through observation, 2 Conroy Close continues to be managed well with a committed staff team. The organisations health and safety policies and procedures are in place. A number of health and safety records were inspected all of which were up to date and accurately maintained. Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 16 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 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 X X X X X 3 X Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? NO 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 YA27 Regulation 23(2)(j) Requirement The registered person must ensure that there are sufficient bathing facilities provided to meet the needs of service users. Timescale for action 14/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Conroy Close (2) DS0000007947.V280355.R01.S.doc Version 5.1 Page 18 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
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