Inspection on 20/09/06 for Conroy Close (2)

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 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conroy Close (2) 27/08/09

Conroy Close (2) 29/08/07

Conroy Close (2) 14/02/06

Conroy Close (2) 11/10/05

Conroy Close (2) 15/03/05

Conroy Close (2) 20/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Conroy Close (2) 2 Conroy Close Easingwold North Yorkshire YO61 3NS Lead Inspector Terry Downey Key Unannounced Inspection 20th September 2006 09:00 Conroy Close (2) DS0000007947.V308531.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 (2) DS0000007947.V308531.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 (2) DS0000007947.V308531.R01.S.doc Version 5.2 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.V308531.R01.S.doc Version 5.2 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. 14th February 2006 Date of last inspection Brief Description of the Service: 2 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 a single storey 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 a housing association and Mencap provides the care. The registered manager is Mrs Susan Palmer. On the 20th September 2006 the fees were £825 per week. Conroy Close (2) DS0000007947.V308531.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 5 hour unannounced site visit to the home on 20th September 2006. At the time of the site visit the manager Mrs S Palmer was available and three members of staff were on duty. Al the service users were in the home but one was going out to her day service. It was difficult to communicate with the residents in the home at the time of the visit. The staff assisted but 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 a well trained 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. The staff are provided with comprehensive training to improve their knowledge and skills. This promotes best practice and ensures that residents receive a good quality service. Conroy Close (2) DS0000007947.V308531.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 (2) DS0000007947.V308531.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 (2) DS0000007947.V308531.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. Service user needs are regularly assessed to make sure that the service can continue to meet 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 (2) DS0000007947.V308531.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. There was no evidence that the residents were part of the process and many of the assessments and care plans were not signed. The manager explained that these matters will be addressed when the person centred planning is fully introduced. 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 (2) DS0000007947.V308531.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. One resident was at a day service during the inspection and others were enjoying individual activities with staff support. It was recommended that the staffing situation be reconsidered to ensure that sufficient staff are available to provide support and do the ancillary and management duties required to run the home effectively. Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 11 There was a lot of evidence in the daily records relevant to the activities the residents’ enjoyed. Menus were varied and nutritionally balanced and the residents are involved in menu planning. Mealtimes were said to be relaxed and social events. Conroy Close (2) DS0000007947.V308531.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 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 good. This judgement has been made using available evidence including a visit to the service. The residents are well supported and the medication procedures ensure that 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. Staff understand the key principles of providing personal support and were responsive to the individual requirements of the residents. Attention was given to ensuring privacy and dignity and staff were aware of, and sensitive to, the changing needs of the residents. The home’s medication procedures were clearly observed and staff were aware of the individual procedure for each resident. Medication was stored securely and all records were well maintained and up to date. Information for each resident was clearly marked and contained information about their individual medicines. None of the residents self medicate. Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 13 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 cover adult abuse training in their induction and foundation training. The manager was aware of the procedure and clear about when incidents need to be reported to other agencies. It was recommended that this be reinforced with the staff at regular intervals. The recruitment procedure is good and ensures that only suitable people are employed in the home. Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 14 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 and kitchen had recently been redecorated as part of a rolling programme of decorations. Residents had all personalised their bedrooms and some had purchased some of their own furniture. There was very good access to the garden which had recently had a makeover and was attractive but also easier to maintain. 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 (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 15 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): 32,33, 34,35, 36. 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 a well trained and committed staff. EVIDENCE: The rota showed that there were sufficient staff on duty but at the inspection it was clear that staff and the manager were very busy trying to meet the changing needs of the residents and carry out the ancillary and management responsibilities. 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. The manager and staff explained that they prioritise the work and the residents take priority but other things, perhaps paperwork have to be left. Formal supervision was not carried out as often as it should have been but the manager works along side the staff and deals with issues as they arise so the formal sessions are missed. There is a core of well-established staff who know the residents well and offer good support to new staff members. It was possible to examine staff files which showed that a safe recruitment procedure is followed to ensure that only suitable people are employed. It was Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 16 however pointed out that an application form with a full employment history / work experience must be received from each new member of staff. A good induction and foundation training programme is in place to ensure that staff are equipped to carry out their jobs well. 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 safety. 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. Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 17 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 available on the day of the inspection and was well organised and helpful. She is open and transparent and leads a staff team that have been recruited and trained to a high standard. 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’. Visitors consulted knew the management structure of the home, and felt that the home was well organised. It was clear that the staffing / management in the home is stretched as mentioned previously and that the work has to be prioritised. The paperwork Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 18 seems to have been the area which has suffered and the slow introduction of the person centred planning, and the lack of formal staff supervision are two noticeable areas. The manager does work alongside the staff and 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 (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 19 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 2 34 2 35 3 36 2 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 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 20 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. Standard YA5 Regulation 5 Requirement The residents must have a contract / terms and conditions relating to the care in the home. The staff rota in the home must be reviewed to ensure that sufficient staff are on duty to reflect the changing needs of the residents The home must ensure that all staff being recruited provide an application form and full employment history Staff must have recorded supervision at least six times per year. Timescale for action 30/11/06 2 YA33 18 30/11/06 3 YA34 19 30/11/06 4 YA36 18 31/12/06 Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 Page 21 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. The adult protection procedure should be reinforced to the staff team at regular times to ensure that they are aware and up to date with it. 2 YA23 Conroy Close (2) DS0000007947.V308531.R01.S.doc Version 5.2 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 (2) DS0000007947.V308531.R01.S.doc Version 5.2 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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