Inspection on 14/06/07 for Noble Lodge

This inspection was carried out on 14th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Noble Lodge 17/12/08

Noble Lodge 11/12/06

Noble Lodge 05/09/05

Noble Lodge 03/05/05

Noble Lodge 09/09/04

Noble Lodge 10/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Noble Lodge 143 Bounds Green Road London N11 2ED Lead Inspector Jackie Izzard Key Unannounced Inspection 14th June 2007 09:00 Noble Lodge DS0000010705.V337222.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 Noble Lodge DS0000010705.V337222.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. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Noble Lodge Address 143 Bounds Green Road London N11 2ED 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) 020 8245 7560 Mr Shaukatally Hossenally Ms Ellen McKinnon Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as the specified service user vacates the home. 11th December 2006 Date of last inspection Brief Description of the Service: Noble Lodge is a private care home providing personal care for 6 adults who have mental health needs. The home, which opened in 1990, is in Bounds Green, close to the underground station and local shops and services. There are six single bedrooms on the ground, first and second floor. There is a small dining room and lounge as well as a small paved garden to the rear. The home is not accessible for wheelchair users. The aim of the home is to provide a quality service for people who have mental health needs and to promote their independence. Noble Lodge aims to achieve this by providing support to help residents maximise their potential, physically, intellectually, emotionally and socially, within a homely atmosphere. The age range of current residents is 39 to 80. At the time of this inspection there were four women and two men at the home. The fees charged range from £500-£700 a week. Noble Lodge intends to make inspection reports available to residents, their families and professionals but has not yet done so. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 1 day. The registered manager was present throughout the inspection and the owner was present for a period of time in the morning. The inspector discussed the requirements made at the previous inspection with him to see what progress had been made. The inspector looked round the home and spoke to 4 of the 6 residents living in the home at the time of the inspection. One was away with relatives and the other was in hospital. Throughout the inspection the way in which staff communicated with and supported residents was observed. In addition one member of care staff, a volunteer and the manager were spoken to. A variety of records, including care plans, staff files and health & safety documents were looked at. What the service does well: Feedback from the residents interviewed was generally positive about how they found living at Noble Lodge. One said “I like it here,” and another said “I don’t do so bad”. A third resident said, “They are alright here, they don’t get on to me too much, they’re alright.” The home has a homely and relaxed atmosphere. Members of staff have got to know the residents very well and understand their individual needs and preferences. As a result residents are able to communicate confidently with staff. Residents are benefiting from being supported by a stable staff team with low turnover of staff. There is an experienced team of staff at Noble Lodge who have attended a range of training courses in working with adults with mental health needs. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: At the previous inspection 16 requirements were made. These were areas to be improved in order to comply with the Care Homes Regulations 2001, the National minimum standards for care homes and to improve the service given to the people who live at this home. It was of concern to find, at this inspection, that seven of the sixteen requirements have still not been fully complied with. These were: • • • • • • • To ensure front and rear areas of the premises are tidied, with leaves, litter and general rubbish removed The laundry area to be cleaned thoroughly to ensure it is hygienic and fit for purpose Communal areas inside the home to be cleaned properly to remove cobwebs and dust (cobwebs have been removed). The manager and staff to undertake training in person-centred planning All staff to have a minimum of 6 recorded supervision meetings each year Findings from quality assurance surveys to be recorded and made available to those parties involved with the home Residents’ meetings and staff meetings to be held at least 4 times each year These requirement are all restated in this report. Unmet requirements impact upon the welfare and safety of people living in the home. Failure to comply by the timescale given will lead the Commission to consider enforcement action to ensure compliance. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 7 Further information regarding unmet requirements can be found in the relevant standard. In addition, at this inspection further requirements are made. These are: • • • • • • • • To carry out a risk assessment for a resident who does not have one To cease the practice of untrained staff giving out medication To update the home’s complaints procedure To complete the fire risk assessment for the home To change the smoking policy for the benefit of non smokers To repair a fire door To carry out a thorough spring clean of the home and carry out some repairs - as detailed in the environment section of this report To produce a development and maintenance programme for the home to improve the environment. All these requirements have an impact on the health or safety of people living in the home. 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. Noble Lodge DS0000010705.V337222.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 Noble Lodge DS0000010705.V337222.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): 2, 5 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home can be confident that their needs will be assessed and an appropriate plan for meeting these needs will be drawn up. EVIDENCE: The files for three of the residents were looked at and indicated that before they moved in a full mental health assessment had been received by the home. A care plan had then been drawn up by the home showing how the resident’s needs were to be met. Reviews with mental health professionals indicated that they considered residents are appropriately placed and their needs are being met. The home operates a four week trial period to see if they can meet the new resident’s needs and whether they are compatible with the existing group. The contract seen in some residents’ files is out of date as it contains information which is no longer accurate. For example, it says that residents should attend a weekly community meeting and that the fee includes a one week holiday, neither of which is currently relevant as there are no weekly Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 10 meetings and the manager said there is no longer a holiday provided. The manager was advised that a new relevant contract be drawn up before any new residents move into the home. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 11 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): 6, 7, 9 People using the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. People are encouraged to make their own decisions about their daily lives. The quality of care provided is adequate but all residents need to be protected by a written risk assessment in order to be assured that staff are aware of the risks to them in leading an independent lifestyle. EVIDENCE: To assess these standards, the inspector looked at three residents’ files for evidence of risk assessments, care plans and reviews. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 12 One person did not have a risk assessment on file. The manager said that she had given this person’s risk assessment to her social worker and there was no copy in the home. This is not acceptable as staff now have no record of the risks to this person to refer to. A requirement is made to carry out another risk assessment. All three had care plans outlining their needs. These had been improved since the last inspection and the resident’s cultural and religious needs have now been included as a result of a requirement made at the last inspection. Care plans had been reviewed regularly. The standard of care plans is basic and a requirement was made at the lat inspection that the manager and staff attend training in person centred planning so that the they would have a better understanding of care planning. This requirement has not yet been met. The owner said they have been unable to find this training. The requirement is restated under standard 35 as the inspector considers that this training will benefit the manager and assist her to improve the quality of care plans at the home. In practice, staff know the residents very well and offer a standard of care which is better than the care plan. The inspector found from speaking with staff and residents that staff know people’s needs very well and residents are generally satisfied with the care they receive. They said that they liked the fact that staff knew them well. The inspector looked records of residents’ meetings for evidence of people being encouraged to make decisions for themselves but these were not taking place regularly. The inspector then asked three people if they were able to make their own decisions on a day to day basis. All three said they made their own decisions. One said that she decided what to eat for breakfast and at what time. She said “they ask me what I like and I have it.” Another said, “they are alright here, they’ve never got onto me”, a third said that s/he felt staff did “nag” but were generally “alright.” They all sad they could come and go as they wished. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 13 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, 15, 16, 17 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People living at this home are able to follow their individual interests and lifestyle choices. They enjoy relationships with their families and are satisfied with the food provided to them. EVIDENCE: The inspector spoke with three residents about their lifestyle in the home and read their records. These standards were also discussed with the manager and a staff member. None of the residents currently attend college or any employment. One goes to a day centre five days a week. Another goes twice a week and one attends luncheon club once or twice a week. Four of the six residents can travel independently to local shops and further afield on public transport. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 14 One person is supported to attend a weekly yoga class which she enjoys. This person said that she enjoyed trips out, going for a walk, yoga, having her nails done and contact with her family. Records showed that these preferences were known and that this person was able to do all these activities on a regular basis. In addition, a carer from Enfield Asian Carers Consortium visits three times a week to support this person with activities. A member of staff was seen to be engaging residents with board games, nail painting and writing activities. Two people enjoy writing, drawing and maths activities and these take place in the dining room. One person is taking part in trips to the coast organised by another organisation. The manager said the home no longer provide a holiday for residents but would be hiring a minibus to take people on trips out in the summer. One person attends church and another occasionally goes to the local pub. Two have no organised activity outside the home. One said s/he did not mind this and was satisfied watching television. The other was in hospital at the time of the inspection. Those residents who have a family have regular contact and three stay with relatives on a regular basis which is very positive. The manager said she has a good relationship with residents’ relatives and keeps in regular contact. The manager escorted a resident to his nephew’s wedding recently and the resident was appreciative of this. All residents are on the electoral register and their polling cards were seen by the inspector as evidence of this. One person told the inspector that s/he had voted. The quality of the food in the home is adequate. One person said they liked the food, that they were vegetarian and their favourite food was cheese sandwiches. One person often has culturally appropriate food brought in by a relative. Two people said the food was “alright” and had no complaints or ides for improvement. The inspector looked at the daily records of what people were eating and this appeared to be of an adequate standard of nutrition. Two residents told the inspector they were consulted daily about what they would like to eat. Noble Lodge DS0000010705.V337222.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 People using the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. Residents receive support with their personal care needs and their physical and mental health needs are addressed. Staff need to be trained in medication so as to protect residents from risk of error in medication . EVIDENCE: To assess these standards, the inspector looked at three care plans and discussed personal support with three residents, looked at health care records, medication and records for staff training relevant to health and medication topics. One staff member was able to describe how the personal support preferences of one resident are met. The resident agreed with what the staff member said and was happy with the personal care support s/he receives from staff. The health records of three residents showed that their health needs were being addressed for both their physical and mental health. One was seeing their GP and a consultant regularly. Another had records of regular Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 16 appointments with a nurse, psychiatrist and optician. Dental needs for all three were discussed and found to be satisfactorily met. The home has an ex staff member who comes into the home a few times a week as a volunteer and often accompanies residents to their health care appointments. Some residents are visited by a Community Mental Health Nurse. One person had attended a smoking clinic. Smoking is a current area of concern in the home. This is addressed in another section of this report. Medication was stored securely and the temperature of the storage cupboard was below 25 degrees as required. Records are kept of all medication which enters and leaves the home and medication daily records were completed to a satisfactory standard. However, the inspector found that only the manager and one staff member had attended accredited training in medication. All staff were giving out medication when they had not all been trained. It is a requirement of the national minimum standards of care homes that staff attend this training and the reason for this is to protect residents from risk of errors and mismanagement of medication. A requirement is made to ensure no untrained staff administer medication to residents. The manager said that this would be easy to implement as the home owners have attended this training and are at the home every day. One person is diabetic and self medicates with insulin. The inspector saw that this medication was stored in the kitchen fridge and the box had food dripped onto it. The manager immediately removed this medication to the staff fridge which is stored more securely and other residents do not have access to. This will be a more suitable place to store this medication. Noble Lodge DS0000010705.V337222.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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and their views are listened to. They would benefit further from a clear complaints procedure should they ever wish to make a complaint. EVIDENCE: There have been no complaints or adult protection issues recorded since the last inspection and the manager confirmed that there have not been any. The complaints procedure needs updating as it states that the second stage of a complaint is to complain to the CSCI which is inaccurate. The manager was advised on updating the complaints procedure to make it clear to residents how to make a complaint. The adult protection procedure in the home is very lengthy and the inspector suggested to the manager that she may wish to shorten and simplify it to ensure staff know exactly what to do if they ever have a disclosure or suspicion of abuse to deal with. Staff have been provided with training in the protection of vulnerable adults. One resident said that if s/he felt s/he was not being treated well, s/he would approach and talk to the manager. Another resident told the inspector that staff had not abused him/her and that s/he knew what to do of this were ever to happen. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 18 Noble Lodge DS0000010705.V337222.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, 26, 27, 28, 29, 30 People using the service experience poor outcomes in this area This judgement has been made using available evidence including a visit to this service. Further attention is needed to provide a clean and comfortable environment for residents to enjoy. EVIDENCE: The environment is homely and all residents have a single bedroom. A number of requirements were made about the building at the last inspection. Some have been complied with and others are ongoing and are still outstanding. In addition, at this inspection there were further areas of improvement identified when the inspector looked in every room and both front and back gardens. One resident’s bedroom was in very poor condition. The inspector was told that staff refused to clean this room and examination of the resident’s care plan confirmed this to be the case. The inspector advised the manager of her Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 20 responsibility to ensure this resident’s health and safety. The duvet in this room was not fit for use and the manager did immediately replace this when the inspector said it must be replaced. A requirement is made about this room. It is the responsibility of the registered persons to keep the home in good condition rather than respond to CSCI requirements for improvement. For this reason, a requirement is made to provide a development plan for the home, which indicates how the home will be maintained and improved over the coming year. The plan must include all the following which were noted during this inspection and all of which must be completed by 30 September: • • • • • • • • • • • • Tidy front and back gardens and remove all rubbish and litter Ensure all curtains are hung properly Remove old wardrobe door from the lounge Fix gutter Provide new garden furniture Clean laundry and dispose of old mattress and other unwanted items Thorough spring-clean of kitchen and clean fridge and freezers Ground floor bedroom – clean, finish decorating and remove all paint spillages, replace broken lampshade Ensure all bedrooms are cleaned and decorated to a suitable standard One specified bedroom must be spring cleaned, redecorated and provide with suitable fire retardant furniture and bedding (by 31 July) Thorough clean of communal rooms including landings and stairwells Adjust kitchen fire door so that it closes properly. This is not an exhaustive list and the registered persons should consult residents and other interested parties for their improvements they would like. Noble Lodge DS0000010705.V337222.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, 35, 36 People using the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. People benefit from a stable vetted and experienced staff team who know them well. Staff receive training to help them develop their competence but do not receive sufficient professional supervsion to support them to develop further. EVIDENCE: The staff team is small but stable and staff have had the opportunity to get to know residents’ individual needs well. The inspector met a member of staff who has worked at the home for eight years and was knowledgeable about her job. As well as discussion with this staff member, the inspector discussed staffing issues with the manager, two residents and examined three staff files to assess the home’s practices in recruitment, training and supervision. The three staff files showed evidence that all three had completed NVQ training at level 2 or 3, which is very positive. All three had also attended training in fire safety, food hygiene and first aid. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 22 All had proper application forms, Criminal Records Bureau disclosures and two references as required. The two residents who spoke to the inspector about staff said that they thought staff were kind and “they are alright”. Staff supervision records showed that the manager had not met the requirement made at the last inspection to ensure all staff receive a minimum of six recorded supervision sessions a year. One staff member had five sessions and the other two had only three. It is of concern that this has been a national minimum standard of five years and the registered persons have yet to comply with it. The requirement is restated in this report. Staffing levels vary ranging from 1 to 3 on duty with 1 at night, sleeping in the office. The manager has an induction programme in place for when the home recruits any new staff. A requirement was made at the last inspection for the manager and staff to attend person centred planning training as this would help develop care practice. The manager said that she had been unable to find any training. The requirement has been amended and restated. The inspector agreed with the manager that if she attended the training, as the person who devises the care plans, she could then train the other staff. Noble Lodge DS0000010705.V337222.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, 42 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health and safety in the home is generally satisfactory but residents will benefit from the fire risk assessment being completed and a review of smoking practices in the home. Further evidence of consultation with residents is needed in the form of regular consultation meetings and writing up the findings of quality assurance surveys for residents to read. EVIDENCE: Staff have attended health and safety training. Training in infection control is planned in the next few weeks. The inspector checked a sample of health and Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 24 safety records and found these to be satisfactory. The fire alarm is tested every week. The last fire drill was on 15 May 2007. The home’s fire risk assessment has been started but is not yet completed. A requirement is made to complete this, particularly as there are two smokers in the home. The fire risk assessment must address the risk of fires in bedrooms where smoking takes place and take action to minimise this risk. Residents are allowed to smoke in the lounge which affects the non smokers adversely. One non smoker was observed to comment that “it’s so smoky in here, I can’t breathe” and another also commented on smoking. The issue of smoking was discussed with the registered persons as they have been making plans for 1 July when new legislation about smoking comes into force. Regardless of this, smoking must not be allowed in a room where the majority of people are non smokers. Requirements to record the findings of quality assurance surveys and hold regular staff and resident meetings are restated as the registered persons have not implemented these. The majority of the surveys had been mislaid during the inspection and the manager said that the findings of the surveys had yet to be written up. Meetings are irregular and advice was given to the manager on how to encourage residents to attend meetings and topics which could be discussed. The manager said that she does consult residents on a one to one basis regarding matters which affect the running of the home. The manager is very experienced at running this home as she has done so for several years. She is not yet qualified and told the inspector she has applied to undertake the registered managers award this year and is waiting to hear whether she has a place on this training. The registered provider attends the home daily and works there so has a good understanding of what is happening in the home at all times. He is also on call if there is a problem at any time. Noble Lodge DS0000010705.V337222.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 2 X X 2 x Noble Lodge DS0000010705.V337222.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 YA9 Regulation 13(4)(c) Requirement The registered persons must ensure a risk assessment is in place for the resident who does not have one. The registered person must ensure that all staff who have not attended accredited training in medication cease administering medication in the home until they have undertaken this training and the certificates as evidence of this have been received in the home. The registered persons must update the complaints procedure to make it clear to residents hw to make a complaint. The registered persons must ensure that the front and rear areas of the premises are tidied up to remove leaves, litter and general rubbish. This requirement is restated. Previous timescale of 31/12/06 not met. Timescale for action 31/07/07 2 YA20 13(2) 07/07/07 3 YA22 22 31/07/07 4. YA24 23 (2) (d) 31/07/07 Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 27 5. YA30 23 (2) (d) The registered persons must ensure that the laundry area is cleaned thoroughly to ensure it is hygienic and fit for purpose. This requirement is restated. Previous timescale of 31/12/06 not met. 31/07/07 6 YA30 13(4)(a) 7 YA24 The registered persons must ensure a specified resident’s bedroom is cleaned, decorated and supplied with suitable fire retardant furniture and bedding 23(2)(b)(c)(d) The registered persons must produce a development plan for the home detailing the maintenance, redecoration and refurbishment plans with timescales for completion and send a copy to the CSCI. 31/07/07 07/08/07 8. YA35 18 ( c) (i) This plan is to ensure continual improvement of the building for residents and must include all the items listed in the environment section of this report which must all be completed by 30 September. The registered person must 31/10/07 ensure the manager undertakes training in personcentred planning. This requirement is restated. Previous timescale of 31/03/07 not met. The registered persons must ensure all staff have a minimum of 6 recorded supervision meetings each year. This requirement is restated. 9. YA36 18 (2) 31/10/07 Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 28 10. YA39 24 (1) Previous timescale of 31/01/07 not met. The registered persons must ensure that findings from quality assurance surveys are recorded and made available to those parties involved with the home. This requirement is restated. Previous timescale of 31/01/07 not met. The registered persons must ensure residents’ meetings and staff meetings are held at least 4 times each year. This requirement is restated. Previous timescale of 31/01/07 not met. The registered persons must complete the fire risk assessment of the home and identify and take action to minimise the risk of fire with regard to smoking in bedrooms. 31/10/07 11. YA39 24 (3) 31/10/07 12 YA42 23(4) 31/07/07 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 YA5 Good Practice Recommendations The registered persons must ensure the contract is accurate and updated before any new resident moves in to the home. Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Noble Lodge DS0000010705.V337222.R01.S.doc Version 5.2 Page 30 - 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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