Inspection on 29/08/07 for Emm Lane Care Home

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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Emm Lane Care Home 29/08/06

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 2007 09:00 Emm Lane Care Home DS0000001139.V339423.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.V339423.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.V339423.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.V339423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 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 people 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 is a walk in shower on the ground floor but the premises are limited for those people with mobility needs. The home is not suitable for wheelchair users. The present fee for the home is from 308.00 per week. Further charges are made for transport, hairdressing, clothes, and cigarettes. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I visited the home unannounced and stayed for approximately 6 hours. The inspection also included gathering information and evidence before and after the visit to decide the overall judgement. The manager was available throughout the inspection. During the visit I looked at the records, watched staff working, and talked to people who live at the home. I also looked around the building. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care. I sent comment cards to people living at the home, relatives, visitors, and social and health care professionals, to give them the opportunity to comment on the service. I received 5 comments cards from people who live at the home letter from a relative and spoke to staff from the community health team. The manager completed a self-assessment form promptly, which helped prepare evidence for this inspection. I talked to the manager about the outcomes of the visit at the end of the inspection. Requirements made during this visit can be found at the end of the report. What the service does well: The manager and staff provide a caring home. Individuals spoken to and comments received from relatives and people living at the home confirmed that the staff were kind and helpful. Comments received are as follows, “ If I have a problem I will speak to the staff” “ All the staff are very nice here. They always treat me well” “ the staff are very respectful and kind and they are a credit to the home” Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 6 Staff are recruited safely and say that they feel well supported to do their jobs and have regular supervision from the management. Staff training is important to the home and over 50 of staff have completed NVQ (National Vocational Qualification) or an equivalent training. What has improved since the last inspection? What they could do better: The care plans and reviews are improved but must provide clearer detail for staff so they know what is expected of them. The care plans and reviews must always include the individual in all aspects of decision-making to make sure they are always involved in important decisions in their life. People’s liberty is at times restricted for their well-being and safety, but the reasons for this are not always clearly recorded. It is not always clear that they had been involved in this decision and how it is being reviewed with them. This can mean that their individual rights are being affected. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 7 Activities in the home and outside have improved and four more care hours a day have been allocated to support this. Going out for walks locally and trips in a minibus are organised. The manager provides a positive experience for people. The range and opportunities for activities still needs to improve particularly for the individual and what they like to do. Many of the people living at the home are unable to go out without staff accompanying them. They are reliant on organised activity and therapy for meaningful stimulation. The manager must seek more ways to make sure these individual needs are met and that people have more opportunities to enjoy a fulfilling life. The records at the home generally were good but improvements in the recording and notifying of incidents was required. Staff must also improve their way of writing personal records to make sure they are objective in their accounts of events. It was also recommended that the a separate health record is maintained for individuals to make sure that health can be better monitored and needs are not overlooked. The home has a maintenance programme but some areas needed prompt attention to be safe and odour problems in some bedrooms must be attended to make sure the home is comfortable. 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. Emm Lane Care Home DS0000001139.V339423.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.V339423.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 4. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s needs are assessed and they are given information and have the opportunity to visit the home before they move in to make sure the service is right for them. EVIDENCE: From talking to staff and looking at the records it was evident that assessments are completed by care management who are responsible for the placement of an individual in the home. This means that the home can be sure it can meet the person’s needs before they move in. Two people who had recently moved in said they had several opportunities to visit and stay at the home before deciding to move in and their families were also welcome to look around. Their social workers and staff confirmed this also. This is important in making sure that people have all the information they need before making the decision to live at the home. Emm Lane Care Home DS0000001139.V339423.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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. 6, 7 and 9. The care plans have improved but people are not always consulted in decisions made about their lives. Individual liberty was at times restricted for their own well being and safety, but it was not always clear that they had been involved in this decision. EVIDENCE: The care plans have improved but need to develop further giving more detail about how the care plan will be met and what is expected of staff. For instance Where the individual’s rights and liberty are restricted this must be part of an ongoing risk assessment and regularly reviewed. For example restricting people’s cigarettes, managing their personal allowance and limiting their access beyond the home, these are all matters that must be discussed and agreed with the individual and then recorded in the care plan. This is to make Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 11 sure that everyone is involved in all aspects of decision-making in their lives and their rights are always protected. The staff review the care plans but they must also be reviewed with the individual (including family, friends and advocates as agreed with them) a minimum of every six months. This is to make sure that any changing needs are met and that people and their representatives are fully involved in any changes to their care plan. The care plans and reviews can also improve by providing clear objectives and goals, which have been discussed and agreed with the person living at the home. The care plans must provide clear instructions for staff to follow so that everyone understands what is expected of them. People do make daily choices at the home, but risk taking is limited. One health professional said that the home was quite limiting for people who were not able to go out independently and staffing levels at times do not always support people enough. Emm Lane Care Home DS0000001139.V339423.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. 12, 13, 15, 16 and 17. People’s privacy is well respected by the staff but the daily records are at times emotive and were not always written in a respectful way. People are offered a good quantity and variety of food that they enjoy. EVIDENCE: People told me that they are encouraged by staff to participate in activities such as board games and arts and crafts. Make up and manicure sessions are also organised. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 13 One individual confirmed that they were encouraged to participate in household tasks such as meal preparation and laundry. One individual also attends a day centre one day a week. People I spoke to and comment cards confirmed that some people are happy to occupy themselves, however other people require more support and some form of activity is needed. Activities are not individually assessed as part of the care plan. The manager and staff have organised activities and then invite people to participate. One health care professional I spoke to felt that access for people living at the home to external day care was very limited and therefore people must have more individual therapeutic activity. Staffing levels have been increased to provide an additional member of staff between 10am and 2pm to provide regular one to one or small group activities in and beyond the home. This means that there are trips to the park, to visit the local museum and use the local tennis courts. Staff assist individuals to enjoy local walks and a mini bus has been hired twice to access places of interest such as Skipton. This has been a positive improvement but the management of the home feel that the fee they are paid to care for people at the home limits how much they are able to provide in terms of one to one support and further activities. House meetings are held where people discuss outings for the summer. They were all asked for their ideas about possible locations for day trips and future visits. Individuals are given a key to their bedroom door if they wish to make sure they can protect their belongings and respect privacy. I saw that staff deal with and speak to people in a respectful manner but daily recordings must also show the same respect. Some recordings are inappropriate and staff must make sure they write a factual and objective account in a person’s daily records. It was recommended “incident” records are completed. This helps staff to define when an unusual or challenging incident has occurred, which may or may not have resulted in an injury to someone. The home specialises in care of people who have a mental health condition and at times incidents do occur that need recording for the well being of everyone. The manager can then easily monitor the type and pattern of incidents, which hopefully can help reduce further risk or incidents. The weekly menu is displayed in the home and people said 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 Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 14 food on the menu. The cultural and diabetic needs of people are met. The manager regularly shops for produce locally and ensures fresh fruit and vegetables are available. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 15 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, 20 and 21. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Everyone’s health needs are met. Medication storage and administration is managed responsibly. Illness and death of people living at the home is handled sensitively and in away the individual and their family would wish. EVIDENCE: Looking through the daily records of the people that were case tracked it was evident that health needs are being met. People are supported in their appointments to visit the Mental Health Services, GP, Opticians, Dentist, and Chiropodist. The District Nurses also support people in the home where required. Finding this information took some time and it is recommended that the home look at a different system of recording to easily identify when Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 16 appointments might be due and make sure that no health needs are overlooked. The medication and medication records were looked at and are all in order. A medication procedure is in place and staff receive advice and support from the local pharmacist. The local pharmacist supports the home with regular visits and provides the staff with training. Relatives commented on how dedicated and supportive the staff have been in cases of long-term illness, they felt that staff deal with these situations with good sensitivity and respect. The following comments were made “ the carers are all very respectful and kind, I do thank most sincerely all those who look after my relative with such loving care and attention and most of all to Mr and Mrs Jomeen” Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 17 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 outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Concerns and allegations are responded to promptly and in accordance with the local adult protection procedures, which make sure that people are listened to and are kept safe. EVIDENCE: There is a clear complaints procedure within the statement of purpose and service user guide. 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. There have been no complaints or concerns in the last year either made directly to the home or to the CSCI (Commission for Social Care Inspection). Staff have a good understanding of abuse and have received in-house training on adult protection. The staff have also had adult protection training provided by the local authority. This means that staff have a better understanding and are aware of their responsibilities to protect people living at the home. The management of personal allowances was reviewed and this was found to be satisfactory. The accounts showed income and expenditure and when people received all their personal allowance to manage themselves they sign the financial record. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 18 Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 19 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, 25, 27 and 30. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Improvements have been made to the environment however further work was required to make sure that all areas were maintained to a good level and were comfortable and safe for people to live in. EVIDENCE: Everyone I spoke to was happy with their rooms and some people had provided additional furnishings and personal items to make their rooms more personable and comfortable. I looked around the building and some bedrooms require maintenance and some have odour problems. One bedroom window needs adjustment to make sure it opens only a minimal amount to ensure everyone is safe. This was all discussed with the manager of the home. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 20 Two of the bedrooms at the home are shared i.e. double bedrooms and the people presently living in those rooms have agreed to share. Screening is not provided in these bedrooms, this is the choice of the individuals sharing the room. The manager is aware that a single room must be offered when available to any individual who shares a room. Some bathroom and toilet doors needed a working lock to make sure that people’s privacy is adequately protected. A new walk in shower has been fitted in the downstairs bathroom, which has improved the facilities for everyone. A new central heating system has been fitted to improve the heating and general comfort within the home. Some decoration has been undertaken but other areas of the home are now in need of redecoration. The owners of the home have a refurbishment plan to continue with the up keep of the home and intend to replace the kitchen in the next few months. The home provides an outdoor shelter, which provides an alternative space for residents who wish to smoke. This area is locked limiting access to the garden; this is for the safety of some of the people living at the home and is agreed with the fire officer. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 21 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 adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People who use the service benefit from staff that are safely recruited and trained to a good standard. The home does not allocate enough staffing hours to effectively meet the social and mental health needs of everyone at the home. EVIDENCE: The recruitment of staff continues to be undertaken safely with adequate checks being undertaken, the most recent recruits to the home are from India and checks have been undertaken in the country of origin and also in this country. Previous training certificates and qualifications were included in the personnel records along with the employment contracts. 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. The home has over 80 of the staff trained to NVQ level or above. This is seen as good practice. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 22 Staff confirmed that they receive induction training and regular supervision and support; they also attend team meetings at the home. The staffing levels at the home provide a minimum of two staff at anytime during the day and a minimum of two staff sleep in the home overnight. The manager is on call near by and is available at the home during the week. There had been some health and safety concerns following the behaviour of one individual who was at times challenging and required one to one staffing. A health care professional said that the needs of some people living at the home do require one to one staffing due to their mental health and the safety of other people living at the home. Staffing levels have recently improved to support people to participate in activities but more staffing hours are needed ensure people are safe and can fully participate in activities and live a more fulfilling life. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 23 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 outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The management has a good approach to the Health and Safety in the home, but must monitor the records and staff to make sure that everyone is aware when an incident occurs. EVIDENCE: A copy of the electrical and gas safety certificates have been sent to the CSCI and are up to date. PAT (Portable Appliance Testing) testing has also been undertaken recently. The home fills in their own fire safety assessment for the fire officer. The manager informed the inspector that the lock on the gate of the covered smoking area has been agreed with the fire officer on the understanding that this is unlocked at night. This is the fire exit from the back Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 24 door. This makes sure that everyone can safely exit in the night if there is a fire. The owners of the home undertakes their own quality assurance monitoring, updating the service user guide, policies and procedures and health and safety monitoring within the home. The home has produced their own quality questionnaires and residents and visitors have completed these. The staff have delegated responsibilities to check health and safety in the home and a monitoring record has been introduced. There have been several incidents occurring at the home, injuries to residents and assaults on both residents and staff, which must be shared with the regulation authority. The manager must make sure that the staff keep her fully informed and monitor such incidents. The manager must inform us of anything that affects the well being of a person living at the home. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 25 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 3 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 3 26 x 27 2 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x x x x 2 x Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 26 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 YA14 Regulation 16 Requirement The registered person must continue to make sure that more stimulation, activities and outings are undertaken people living at the home. Previous timescales 01/11/06 not met. Timescale for action 01/11/07 2. YA6 15 The continued assessments and 01/11/07 care plans must be person centred and include all aspects of individual aspirations, social and cultural needs. Previous timescales 01/11/06 not met. The decisions made in the review 01/11/07 must be clear and instruction to staff detailed to make sure that people’s decisions are taken into account and their needs are met. The reviews must be held a minimum of 6 monthly intervals. The bathrooms and toilets 01/11/07 identified with the manager must have the locks repaired to make sure that people have privacy. The odour problems in the 01/11/07 bedrooms discussed with the manager must be managed to DS0000001139.V339423.R01.S.doc Version 5.2 Page 27 3 YA6 15 4 YA27 23 5 YA25 23 Emm Lane Care Home 6 YA33 18 make sure that people have a comfortable bedroom. The registered provider must maintain adequate staffing levels to make sure that people are able to live their lives to their full potential. 01/11/07 7 8 YA42 YA42 23 37 Any windows above ground floor 01/11/07 must be safely restricted to make sure the people are safe. Any incidents or accidents in the 01/11/07 home, which affect the well being of the people living at the home must be notified to us. This will make sure that any issues are being managed in the best interests of the people living there. 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 YA42 Good Practice Recommendations It was recommended that the home complete an incident form where an unusual or challenging incident occurs that may or may not result in an injury. This will make sure such incidents are being managed in the best interests of the people living there. Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Emm Lane Care Home DS0000001139.V339423.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!