Inspection on 29/08/06 for Emm Lane Care Home

This inspection was carried out on 29th August 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Emm Lane Care Home 29/08/07

Emm Lane Care Home 31/01/06

Emm Lane Care Home 24/05/05

Emm Lane Care Home 23/02/05

Emm Lane Care Home 05/05/04

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 Emm Lane Care Home 72 Emm Lane Heaton Bradford West Yorkshire BD9 4JH Lead Inspector Linda Trenouth Key Unannounced Inspection 29th August 2006 9:30 Emm Lane Care Home DS0000001139.V298901.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 Emm Lane Care Home DS0000001139.V298901.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. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emm Lane Care Home Address 72 Emm Lane Heaton Bradford West Yorkshire BD9 4JH 01274 541444 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) Mrs Kim Helen Jomeen Mrs Kim Helen Jomeen Care Home 14 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (12), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (12) Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Emm Lane Care Home was first registered in November 1986 with Mrs. Kim Jomeen taking on the roles of manager/provider. The home is situated near Lister Park approximately 3 miles from Bradford city centre. The area is well serviced by public transport to Shipley and Bradford. The house is a semi-detached period property, providing care and accommodation to service users of either gender aged 40-80 years who are recovering from a mental illness. The accommodation is situated on three floors, with two double and ten single bedrooms. There are two lounges and a dining/kitchen. There are no special facilities provided for those with mobility needs. The home is not suitable for wheelchair users. The present range of fees for the home is between £410-420 per week. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, “ Choice of Home” and “Leisure”. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was an unannounced key inspection carried out by one inspector who was at the home for approximately 7 hours. The main purpose of this inspection was to make sure that the home provides a good standard of care for the residents. The methods used at this inspection included looking at care records, observing working practices and talking to residents and staff. Comment cards were left at the home to provide residents and visitors with the opportunity to comment on the service. No comment cards were received at the writing of this report, any received in future will be included in the next report. Feedback was given to the registered provider Mrs Jomeen and her husband at the end of the visit. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of the report. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home has improved the care plans and reviews over the last two years but further improvements are needed. The assessments and care plans must include all aspects of the individual, be person centred and include personal aspirations, social and cultural needs. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 7 Some activities have been organised, but the staffing levels at the home must provide enough time for staff to provide meaningful individual activities for everyone. Leadership and guidance needs to be provided to the staff team to undertake these activities. The home must provide training for all staff in first aid. The ground floor bathroom does not meet the personal care needs of all the residents. The home has proposed a conversion of a bathroom to a walk in shower. This must be completed, as a matter of urgency as the home cannot meet the personal care needs of all the residents in the home. The registered provider must maintain full records on health and safety checks undertaken in the home, this includes certificates of safety for the Electrical and Gas supplies in the home. The present staffing arrangements are that two staff are “sleeping in” on call in the home through the night. The dependency of a service user has recently increased. When the needs of a service user change the staffing levels must be reviewed. The registered provider must maintain adequate and safe staffing levels day and night to safely meet the needs of the residents. 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. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 8 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 Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 9 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 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ individual needs are assessed prior to them moving into the home by the placing authority. Prospective residents have the opportunity to test drive the home, with exception of emergency placements. EVIDENCE: From discussion with staff and the review of records it was evident that assessments are completed. The assessments are undertaken by care management who are responsible for the placement of an individual in the home. The prospective resident and their family are invited to visit and stay to meet the residents and staff. The most recent resident in the home had been an emergency admission and therefore an introductory visit had not taken place, however an assessment had been provided. Previous admissions to the home had the opportunity and were encouraged to “try out” the home before they moved in. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 10 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, 8 and 9. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The care home’s assessment of the residents’ needs is limited. The care plans are not person centred and do not reflect individual social needs and aspirations. The care plans do not effectively involve all care staff and structure of the plans do not provide enough guidance to staff on how to meet residents needs. EVIDENCE: The home have over the years improved their care plans and reviews and this is acknowledged but they will need to develop further if they are to address fully the needs of all residents in the home. The individual assessments are limited; the documents assess health and care needs but do not assess individual interests, social needs, aspirations, and Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 11 cultural needs. Although there was evidence to show that some care reviews have taken place, care plans had not been updated accordingly. It is however good practice that the residents are involved with their assessments and care plans and individuals sign the care plans and reviews to confirm their involvement and consent. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 12 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, 15, 16, 17. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There has been some improvement in activities but the opportunities for individual activities are still limited by staffing levels at the home. Residents are offered a good quantity and variety of food that they enjoy. EVIDENCE: Staff encourage activities such as board games and arts and crafts are made available in the home. Make up and manicure sessions are also organised. During the inspection one resident confirmed that they were encouraged to participate in household tasks such as meal preparation, laundry, hanging out washing and cleaning of their own room. Two residents also attend day centres. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 13 Some residents were happy to occupy themselves and had good independent living skills, however other residents required support and some form of therapeutic intervention was needed. The staffing duties are such at the home that care staff undertake all care, cleaning and cooking duties and any activity is undertaken when these tasks are completed. Staff also appeared to lack direction and leadership and confidence to undertake activities. Residents have held meetings since the last inspection to discuss outings for the summer. They were all asked for their ideas about possible locations for day trips and short holidays, one trip to Skipton and one to Otley has been organised. The weekly menu is displayed in the home and of the residents spoken to they said that they were very happy with the food at the home. They all felt there was enough food provided throughout the day and that alternatives were made if they did not like the food on the menu. The cultural and diabetic needs of residents were met. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 14 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 and 21. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The resident receives personal support in a way they prefer and require. Medication storage and administration is managed responsibly. The illness and death of a resident is handled in away the individual and their family would wish. EVIDENCE: The health needs of individuals are reviewed regularly and residents are supported in their appointments to the Mental Health Services, GP, Opticians, Dentist, and Chiropodist. The District Nurses also support residents in the home and visit daily. The home support individuals to attend appointments and reviews with their Consultant and CPN (Community Psychiatric Nurse). The medication and medication records were reviewed and were all in order. A medication procedure was in place and staff received advice and support from the local pharmacist regarding the administration of medication. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 15 Discussion with staff and review of records confirmed that the recent long term illness and death of a resident was handled with sensitivity and respect. The home respected her wishes to remain at the home as long as possible. The resident had lived at the home for some considerable time. Mrs Jomeen ensured that all her comforts were met and the staff gave sensitive support throughout the illness. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The responsible person responds promptly to any concerns and allegations made and works with the local adult protection procedures. EVIDENCE: The complaints procedure was seen within the statement of purpose. This procedure is in a simple format and reassures complainants that their complaint will be investigated. It is also displayed clearly in the home in both English and Urdu. Records of all complaints are kept along with how the complaint has been investigated. Staff have a good understanding of abuse and have received in-house training on adult protection. The staff at the home are waiting for a training date on the adult protection course run by the local authority. There has been one adult protection referral with regard to staff conduct, which has now been investigated and resolved. Appropriate support was provided to the service user by their social worker during this period. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 17 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, 27, 29 and 30. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home has continued to improve in decoration in the communal areas of the home and some residents’ bedrooms. The personal care needs of the residents are not met by the present provision of bathrooms/ shower rooms in the home. EVIDENCE: Some redecoration has been undertaken within the home in communal and bedroom areas. This has improved the appearance and quality of the overall environment. The home has now provided an outdoor sheltered area, which provides an alternative space for residents who wish to smoke. All areas of the home seen were clean and free from odour. The bathroom on the ground floor is inadequate to meet the needs of the residents who are less mobile or have physical needs. Mrs Jommen has said Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 18 that some estimates have been obtained for the work to alter the downstairs bathroom to a walk in shower facility; this must be completed, as the personal care needs are not being appropriately met due to the lack of facilities. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Adequate staffing levels must meet the needs and safety of residents. EVIDENCE: The staffing levels at the home provide a minimum of two staff at anytime. Staff are available throughout the night on a sleeping in basis. Concerns were raised that due to increased physical dependency one resident’s needs requires two staff to safely assist them. The home must show that it is able to provide this level of assistance throughout the night. Staffing levels may need to increase to meet this need; the home must review the staffing levels throughout the night in consideration of this increased dependency. The home continues to have a commitment to NVQ training and with the recent introduction to the team of four overseas staff the required NVQ training standard has been met. One member of staff is on the NVQ level two training award with three further members of staff commencing in September. It was recommended that the home provide English language courses for some of the care staff recently joining the team from abroad. This is to improve communication, understanding and support for the residents. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 20 The recruitment records were reviewed and included; application forms references and CRB checks for al l new staff at the home. Previous training certificates and qualifications were included in the personnel records along with the employment contracts. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 21 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, 40 , 42 and 43. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home generally has a responsible approach to the Health and Safety of the residents, however proof of electrical and gas safety testing has not been provided in the last year. The home has their own quality assurance system, which is appropriate to the size and needs of the home. EVIDENCE: The electrical and gas safety certificates must be made available to show essential safety tests have been completed and recommendation put into action. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 22 The owners of the home undertake their own quality assurance monitoring, updating the service user guide, policies and procedures and health and safety monitoring within the home. The staff have delegated responsibilities to check health and safety in the home and a monitoring record has been introduced. The home has produced their own quality questionnaires and residents and visitors have completed these. Residents are encouraged to participate in their reviews and house meetings to involve them in decision making in the home. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 23 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 3 5 x 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 2 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 x LIFESTYLES Standard No Score 11 x 12 2 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 3 x 2 3 Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 24 Yes 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 YA6 Regulation 15 Requirement Timescale for action 01/11/06 2 YA14 16 The continued assessments and care plans must be person centred and include all aspects of individual aspirations, social and cultural needs. There must be more stimulation, 01/11/06 activities and outings undertaken with service users. (This is a previous requirement from the 1.09.04 and 20/08/05 01/04/06, which were as not met). First aid training must also be provided to all staff. Bathrooms/ shower rooms on the ground floor must meet the personal care needs of the residents. The registered provider must maintain adequate and safe staffing levels day and night. Safety certificates must be obtained to show that Gas and Electricity systems within the home are safe. Copies must be sent to CSCI at Rodley. 01/12/06 01/11/06 3 4 YA20 YA27 18 16 5 6 YA33 YA42 18 13 01/11/06 01/11/06 Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 25 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 YA32 Refer to Standard Good Practice Recommendations It was recommended that the home provide English language courses for some of the care staff recently joining the team from abroad. This is to improve communication, understanding and support for the residents. Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Emm Lane Care Home DS0000001139.V298901.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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