CQC report explained · a residential care home
What the CQC found at Emm Lane Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and inspectors found suitable risk assessments, safety checks, safeguarding procedures and staffing arrangements. Medicines were managed safely, with detailed weekly and monthly checks.
- Effective?
- Good
- People's needs were assessed and care plans gave staff clear information. Staff were trained and supported, although some had not received the minimum frequency of supervision set out in the home's policy.
- Caring?
- Good
- People and relatives described staff as kind, caring and supportive. Inspectors saw people being treated with dignity and respect, offered choices and encouraged to remain independent.
- Responsive?
- Good
- Care plans were personalised, regularly reviewed and understood by staff. People were supported with activities, relationships and community involvement, but end of life wishes were not recorded in detail.
- Well-led?
- Good
- Managers were visible and approachable, and quality checks were in place. However, the provider had not recently surveyed people and relatives, and complaints were not being monitored for themes or lessons.
What inspectors found, February 2020
Emm Lane Care Home was rated Good; inspectors found safe, kind and personalised care, with some records and improvement work still needed.
This was an unannounced inspection on 28 January and 4 February 2020. One inspector spoke with five people, five staff, a health professional and a relative. They also checked care records, medicines records, staff files and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and secure. Inspectors found kind staff, personalised care, safe medicines management and good links with health and social care professionals.
The Safe rating improved from Requires Improvement to Good since the last inspection. Other ratings remained Good. Inspectors identified some areas to improve, including the frequency of staff supervision, end of life care planning, complaints monitoring, surveys and worn furniture and decoration.
Safe environment
The home had improved lighting and decoration since the previous inspection. Daily safety checks were comprehensive and identified issues were dealt with promptly.
“At this inspection improvements had been made. Lighting and internal decoration had been replaced and all areas of the home were bright and well lit.” from the report
Safe medicines
Staff received medicines training and competency checks. Audits were more detailed than at the previous inspection, and people were supported patiently.
“At this inspection we found detailed weekly and monthly checks were completed.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw warm, respectful interactions and support that encouraged independence.
“Staff had a compassionate approach and we observed them showing respect and kindness when speaking with and supporting people.” from the report
Personalised support
Care plans were detailed and up to date. Staff knew people's preferences, needs and ways to support their mental health.
“People's care needs were assessed, and they received person-centred support from staff who understood their needs well.” from the report
Approachable management
Managers were visible and listened to staff and residents. The home had organised systems for checking quality and responding to issues.
“The management team were visible and approachable. We saw there was a warm rapport between the managers, staff and people who lived at the home.” from the report
Staff supervision
needs fixingThe home's policy said staff should receive at least four supervision sessions a year, but some staff had not received this. Management acknowledged that more work was needed.
“The homes' supervision policy stated staff should receive a minimum of four supervisions a year, but some staff had not received this frequency.” from the report
End of life plans
needs fixingNo one was receiving end of life care during the inspection. The report said people's wishes had been discussed, but the recorded information was not detailed.
“People's end of life wishes were discussed as part of the assessment process but the information was not detailed.” from the report
Complaints monitoring
needs fixingPeople and relatives felt able to raise concerns, but the home did not have a system to identify complaint themes or lessons learned.
“There were a low level of complaints however, there was no system in place to monitor any themes or lessons learned.” from the report
Worn furnishings
minorSome furniture and decoration looked tired and worn. Managers said refurbishment and redecoration were ongoing.
“In some areas the furniture and décor were tired and worn.” from the report
Feedback surveys
minorThe provider had not recently surveyed people and relatives about their views. Managers said they planned to do this.
“The provider had not conducted any recent surveys to gather people and relatives' views.” from the report
- 01How many supervision sessions has each staff member received since this inspection, and how are missed sessions prevented?
- 02How do you now record people's end of life wishes and make sure staff have the training to follow them?
- 03How do you monitor complaints for recurring themes and use them to improve the home?
- 04Have people and relatives now been surveyed, and what changes were made in response to their feedback?
- 05Which furniture and decoration improvements have been completed since the inspection?
This was an unannounced comprehensive inspection covering all five CQC questions; the Safe rating improved from Requires Improvement, while the other ratings remained Good. This explanation was written from the published report of 18 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2017
Rated Good overall; inspectors found kind, effective care, but Safe was rated Requires Improvement because some safeguarding and medicines records needed strengthening.
Inspectors visited the home without warning on 14 June 2017. They reviewed four care records, policies, audits and staff files. They observed care and spoke with people living there, staff, management and a visiting health professional.
People told inspectors they felt safe and were treated kindly. Staff supported people with food, health care, activities and daily choices. Inspectors found good relationships, a calm atmosphere and care that promoted independence.
The main concerns were under Safe. One suspected financial abuse incident had not been reported as a safeguarding concern. Information about covert medicines was incomplete, medicines audits were basic, the medicines policy needed updating and some areas needed better lighting.
The overall rating of Good means the service met the inspectors' expectations in most areas. Safe was rated Requires Improvement, while Effective, Caring, Responsive and Well-led were all rated Good. Improvements had been made since the previous inspection, and the home was no longer in breach of the earlier regulations.
Kind and respectful care
People said staff were kind and treated them well. Inspectors saw gentle, respectful interactions and a relaxed atmosphere.
“People told us staff were kind and treated them well.” from the report
Support for independence
People were encouraged to help with meals and other daily tasks. They could choose activities and were supported to take part in life outside the home.
“People were supported to be as independent as possible.” from the report
Health and nutrition
People had access to a range of health services. Their weight and dietary risks were monitored, with referrals made when needed.
“From reviewing care records and speaking with staff and people living at the service, we saw people had access to a wide range of healthcare services.” from the report
Improved management systems
The home had introduced audits and daily checks to monitor safety and quality. These checks led to changes such as reviews of medicines and care plans.
“These showed audits were being used as a working quality tool to help improve service provision and keep people safe.” from the report
Safeguarding report missed
seriousOne suspected financial abuse incident was recorded as a complaint instead of being reported to the local authority and the CQC. Inspectors considered this an isolated omission, but the home needed to ensure future concerns were reported correctly.
“However, we saw one instance of suspected financial abuse between two people living at the service had not been reported to the local authority or the Care Quality Commission.” from the report
Covert medicines records
needs fixingThe best-interests process for one person's covert medicines had taken place, but the pharmacist's instructions were not recorded in the care record.
“However, the decision process had not recorded the pharmacist instructions.” from the report
Medicines policy and audits
needs fixingMedicines were generally managed safely, but the policy did not reflect current legislation and the audits were basic. The report says both needed strengthening.
“Medicines audits were in place although these were basic and would benefit from further detail.” from the report
Poor lighting in some areas
needs fixingThe home had improved its environment, but some internal areas remained poorly lit. The provider told inspectors there were plans to renew the lighting.
“However, we saw some interior areas remained poorly lit, for instance, the inner landing on the first floor.” from the report
Some records needed updating
minorMost care plans reflected people's current needs, but some information needed updating. Some staff supervisions and appraisals were also overdue.
“We saw people's needs were assessed prior to admission and plans of care were put in place.” from the report
- 01What has been changed to make sure every safeguarding concern, including suspected financial abuse, is reported to the local authority and the CQC?
- 02How are decisions about covert medicines recorded now, including the pharmacist's instructions?
- 03Has the medicines policy been updated to reflect current legislation, and how detailed are the medicines audits now?
- 04Has the poor lighting on the first-floor inner landing and in other areas been improved?
- 05How do you make sure care plans, staff supervisions and appraisals are kept up to date?
This was an unannounced inspection covering all five quality questions, with the overall rating and each question rating assessed during the visit. This explanation was written from the published report of 20 July 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Emm Lane Care Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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