Inspection on 01/08/08 for Tulips Care Home, The

This is the latest available inspection report for this service, carried out on 1st August 2008.

CSCI found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tulips Care Home, The 11/05/06

Tulips Care Home, The 09/12/05

Tulips Care Home, The 07/10/05

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Chatsworth Care - Dawson House

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Townley Road, 2-3

Chatsworth Care - Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Tulips Care Home, The 326 Hither Green Lane Hither Green London SE13 6TS Lead Inspector James O`Hara Unannounced Inspection 1 & 4th August 2008 09:15 st Tulips Care Home, The DS0000058570.V368835.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 Tulips Care Home, The DS0000058570.V368835.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. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tulips Care Home, The Address 326 Hither Green Lane Hither Green London SE13 6TS 020 8695 1175 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) ammouymcfarlane@btbroadband.com Tulips Care Home (The) Navlette Ommouy McFarlane Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2007 Brief Description of the Service: The Tulips Care Home is a large detached two-storey house situated just off the South Circular Road South London, providing care and support for up to four female adults aged 18 to 65 Years. It is registered for providing a service for people with Learning Disability and Mental Health support needs. The home is convenient for public transport to Central and South East London and is a short walk to local shops, and a 10 minute bus ride to Lewisham or Blackheath, offering a range of shops and cafes. The home has space for three cars in the front and has ample on road parking nearby. All residents have their own rooms located on the ground and first floors. Bathing facilities are made up of a shower room and toilet on the ground floor, and a bathroom/toilet on the first floor. There is a medium sized garden to the rear of the house that is attractive and developed and is accessible from the downstairs hallway. The home is privately run and owned by the registered manager and first opened in March 2005. The home’s philosophy is to encourage participation in the dayto-day running of the home and in the local community. The staff complement comprises the registered manager and five other female staff, with minimal use of agency staff. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The current fee for staying at the home is between £700 and £750 per week, this covers all of the homes charges including food. Residents have to pay for other personal expenses such as hairdressing, transport and personal shopping. The provider’s email address is: ammouymcfarlane@btbroadband.com Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. We spent four and a half hours over two days at the home and talked with four residents, the registered provider/manager, the deputy manager, one member of staff and a visiting community psychiatric nurse. Records and documents examined during the inspection included the Statement of Purpose, Service Users Guide, person centred plans, care plans, risk assessments, medication, staffing and training records. Information was taken from a number of surveys returned to the Commission from residents and staff. The home completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people using it and any planned developments. What the service does well: Good information is available to people about the home. The needs of any new residents would be fully assessed to make sure that the home is suitable. Residents have good person centred plans and care plans that give good information about their support needs. Risk assessments are completed to help people live as independently as they can. The community psychiatric nurse told us “ I am impressed, all of the women living at the home came from places were they were quite vulnerable and at risk but they have all kept really well since coming to the home, they all felt secure, safe and respected and are always telling her they want to stay at the home”. Residents are able to take part in activities and be part of the local community. One resident told us “I like living here, I can come and go as I please, the staff are very friendly and cooperative, I like sitting in the garden and going out” and “I have regular visits from my daughter and my sister, I can see them in my room or sit in the garden if it is a nice day”. Another resident told us “I am going out this afternoon to a barbeque, I go out a lot sometimes with staff to the pub or for something to eat”. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 6 Medication is well managed by the home. One resident told us “my medication is well looked after which really helps me, it makes me feel good because this is very important for me”. The community psychiatric nurse told us “I believe the Tulips has provided a supportive and caring environment in which my client has flourished”. She also told us “the registered manager is brilliant and communication between the home and my team is really good”. People living there enjoy the food provided. The home received a four-star hygiene rating from Scores on The Doors for good food safety management and a high standard of compliance with food safety legislation. Residents live in a clean, comfortable and homely environment and are encouraged to personalise their rooms. Staff have good training opportunities. The recruitment process is good with systems to make sure that appropriate checks are made. One member of staff commented, “the home caters for all of the residents needs individually, we have very good care plans and staff development training”. The home is well run. Good Quality Assurance systems and good Health and Safety arrangements are in place. What has improved since the last inspection? What they could do better: Staff supervision sessions need to take place more often and be recorded. Staff contracts need to be reviewed to ensure that they accurately reflect the hours worked by staff. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 7 We would like to thank the resident’s, the community psychiatric nurse, staff and the registered manager/provider for their comments and support during the inspection process. 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. Tulips Care Home, The DS0000058570.V368835.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 Tulips Care Home, The DS0000058570.V368835.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 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People planning to use the service have good information about the home and they can be sure that the home can meet their needs because their needs are fully assessed before they move in. EVIDENCE: The registered provider produced the homes Statement of Purpose & Service Users Guide. Both documents had recently been reviewed and include all of the details as required in Schedule 1 of the Care Home Regulations. No new residents have moved into the home since the last inspection. There are no vacancies at the home at present. The registered manager told us that any new residents would be assessed by the home with input from care managers, care co-ordinators and the community psychiatric team if required to ensure that the home could meet the new residents needs before they were offered a placement. The Statement of Purpose and Service Users Guide include a detailed description on referrals, fair access, eligibility criteria, needs assessments and introductory visits to the home. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 10 Residents have contracts detailing what they should expect from the home and how much they have agreed to pay. Those sampled indicated that they been agreed and signed by the residents, their representatives and the registered manager. The current fee for staying at the home is between £700 and £750 per week. Tulips Care Home, The DS0000058570.V368835.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 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents can be sure that they are properly supported because person centred plans and care plans give good information about their support needs and how the home can meet these needs. Risk plans are completed so that people can live as independently as possible. EVIDENCE: A requirement was set at the last key inspection that the registered manager must ensure that residents care plans and reviews are signed and dated by both the manager and the resident. All shift handover sessions between care workers must be signed by the individuals present. Two residents personal files were sampled at random. Both residents’ files included person centred plans. These plans referred to the residents preferred support with personal care, daily activities, feeling safe and secure, routines, Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 12 relationships including religious needs and sexual preferences, confidentiality and their hopes and dreams. The registered provider told us that staff supports the residents to meet these needs and preferences. Both residents’ files included detailed care plans (signed and dated by the manager and the resident) that included information on how staff can support them with their mental health, medical, physical and dietary needs, the file also included an up to date health action plan. Staff also completes a monthly progress report to monitor how the residents needs are being met. Six monthly reviews and a care programme approach are also carried out. These were examined and indicated that they were attended by the resident, community psychiatric nurse/care co-ordinator, the registered manager and a consultant psychiatrist. Files also included individual risk assessments. Risk had been assessed on aggression, getting lost, epilepsy, bathing, isolation, sexual relationships, sore skin, depression, using the kitchen and residents storing medication in their own bedrooms. Tulips Care Home, The DS0000058570.V368835.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 and 17. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that their social and leisure needs are met because they are offered a varied programme of activities that reflects their individual interests. Appropriate arrangements are made so that residents can have regular contact with their friends and families. EVIDENCE: The registered manager told us that some residents attend the Granville Centre and the Leigh Centre for arts and crafts, drop in, women’s afternoons and go out into the local community to pubs, museums, restaurants for lunch and the theatre. Some residents prefer to go out alone and do their own things and some residents prefer staying at home. Residents are always offered the Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 14 opportunity to attend activities and are able to make their own decisions I they want to go or not. The registered manager told us that the Community Opportunities Service also supports the home; a key worker visits residents at the home to discuss and plan activities. An exercise teacher visits the home every other weekend to help the residents keep fit. One resident told us that she was going back to cookery lessons and another resident told us that she is planning to attend guitar lessons in September at a local college. Residents told us that they like the activities offered to them at the home. One resident told us “I like living here, I can come and go as I please, the staff are very friendly and cooperative, I like sitting in the garden and going out”. Another resident told us “I am going out this afternoon to a barbeque, I go out a lot sometimes with staff to the pub or for something to eat”. The home has a policy of encouraging and supporting residents to maintain contact with family and friends and in supporting personal relationships. The homes visiting policy is referred to in the Statement of Purpose and Service Users Guide, visitors are expected to sign a visitor’s book and visiting times are between 11am and 9pm seven days of the week. One resident told us “I have regular visits from my daughter and my sister, I can see them in my room or sit in the garden if it is a nice day”. The registered manager told us that she was considering building a conservatory so that residents can receive visitors there on colder days. One resident has no family and the registered manager has tried to obtain an advocate, however she this resource is in short supply locally. The registered manager has referred the residents to Time Out, a service users escort project and all of the residents are on the waiting list. One resident told us “the food is nice” another resident told us “the food is delicious”. A member of staff offered us lunch, lunch was haddock, mashed potato and mixed vegetables, the meal was presentable and very tasty. Menus are planned on a rolling menu system showing weeks 1 to 4. Residents told us that they were involved in shopping and were offered a choice of what to eat. Residents have full access to the kitchen facilities and can make snacks as they wish to, and are involved in cooking activities alongside staff members. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 15 The home received a four-star hygiene rating from Scores on The Doors for good food safety management and a high standard of compliance with food safety legislation. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 16 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 and 20. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that their health care needs are met because medication is well managed by the home and they have good access to appropriate healthcare professionals. EVIDENCE: One resident told us “my medication is well looked after which really helps me, it makes me feel good because this is very important for me”. Residents’ files included detailed care plans that included information on how staff can support them with their mental health, medical, physical and dietary needs, the file also included an up to date Health Action P DCA lan (HAP). The care plans indicated that the home has very good links with the community psychiatric team and other health care professionals and they are regularly consulted by or about the residents. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 17 The HAP included a record of resident’s appointments with chiropodists, dentists, opticians; medication reviews and physical check ups with General Practitioners. A community psychiatric nurse was visiting the home, she told us “one resident was quite ill and it was considered that she might need to go into hospital however due to the home working hard with the community psychiatric team and other health care professionals the resident has really improved”. The registered manager told us that one resident has diabetes, a specialist diabetic nurse visited to home to offer advice on diabetes and train staff on how to carry out blood tests to monitor the residents sugar levels. The registered manager produced evidence that all staff has attended training on moving and handling, medication, dementia, mental health, diabetes and epilepsy in order to meet the diagnosed conditions of the residents. The registered manager told us that staff would attend training on first aid, nutrition and customer care in September 2008. Medication is stored in locked cabinets in resident’s bedrooms. None of the residents self medicate. A requirement was set at the last key inspection that the registered manager must ensure that all medicine cabinets are securely affixed to walls with “rawl bolts”. Also any handwritten entries on medication administration records (MAR) are countersigned to avoid mistakes being made. Three medicine cabinets were examined. Only one had been fixed to walls with “rawl bolts”. The registered manager told us that this cabinet was the one that the requirement referred to; it was pointed out to the registered manager that the requirement referred to all of the medicine cabinets. The registered manager told us that she had misunderstood the requirement and made arrangements for the other cabinets to be fixed to walls with” rawl bolts”. It was agreed that we would return after the weekend to see that the work had been completed. When we returned to the home the following Monday, the registered manager showed us that all of the medicine cabinets had been fixed to walls with “rawl bolts”. The part of the requirement relating to handwritten entries on the (MAR) sheets needing to be countersigned to avoid mistakes being made was discussed. This part of the requirement was removed when the registered manager told us that as only one member of staff worked on the late shift so it was not possible to meet this, however the she produced evidence that stocks and balances of medication is checked on a regular weekly basis. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 18 Medication administration records were examined for all of the residents for June and July. There was one occasion when medication had been administered but not signed for by staff. This happened the evening prior to the inspection, the registered manager confirmed that the resident had been administered the medication but that the member of staff on shift had not signed the (MAR) sheet. The registered provider produced evidence that all members of staff attended training on medication and administering on the 24th of May and medication was regularly discussed at team meetings. The registered manager told us that she would discuss the importance of making sure that medication administration records are properly completed with the member of staff concerned. When we returned to the home the following Monday, the registered manager told us that she had discussed this issue with the member of staff. The registered manager told us that advice was readily available from the supplying pharmacist and that the pharmacist had agreed to do periodic medication audits for the home. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 19 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 using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that their complaints and concerns are listened to because the home has a clear complaints procedure that that they can understand. Residents can be sure that they are protected from harm and abuse because the home has policies in place for safeguarding adults and staff has completed training on adult protection. EVIDENCE: The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. All residents have the capacity to raise concerns and those spoken to indicate that they were very happy within the home and had no complaints. The registered manager confirmed that no complaints had been received by the home since the last inspection. Three residents told us that they knew how to make a complaint and who to complain to if the need arose. All of the residents told us that they had no cause for concern and they were well looked after at the home. The home had policies and procedures in relation to adult protection and has a whistle blowing policy. No allegations of abuse had been made to the provider Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 20 or the Commission since the last inspection. The home has a copy of the London Borough of Lewisham Safeguarding Adults Procedures and all staff has attended training on the protection of vulnerable adults and safeguarding adults. Risk assessments regarding residents managing their own finances are in place. The system for dealing with residents, personal monies was examined and found to be accountable with a good audit trail. Monies were retained in a lockable safe in the manager’s office with individual envelopes for residents. Ledger accounts and receipts obtained. The community psychiatric nurse visiting the home told us “ I am impressed, all of the women living at the home came from places were they were quite vulnerable and at risk but they have all kept really well since coming to the home, they all felt secure, safe and respected and are always telling me they want to stay at the home”. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 21 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 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained so that residents can live in a clean, comfortable, homely and safe environment. EVIDENCE: The home was clean, bright and comfortable and is well suited for its purpose. All residents have their own rooms located on the ground and first floors. Bathing facilities are made up of a shower room and toilet on the ground floor, and a bathroom/toilet on the first floor. There is a medium sized garden to the rear of the house that is attractive and developed and is accessible from the downstairs hallway. Bedrooms are personalised by the individual residents, and there was evidence of residents’ interests and personal possessions in each room. Bedrooms are spacious and had facilities available for residents’ personal storage. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 22 The home is generally well maintained and kept clean and safe. There is sufficient light and ventilation and furnishings are adequate. The registered manager completes weekly health and safety checks and is using a comprehensive written system for recording findings and action required. Planned repairs/renovations required to the home are being properly recorded and included in a development plan or addressed immediately or when necessary. The registered manager has recently purchased a new washing machine and tumble drier for the home, some residents bedrooms have had new curtains and carpets and have been redecorated. The home is kept clean and hygienic, and checks are carried out regularly to ensure health and safety requirements are maintained. The bathroom, shower room, laundry area and toilets were well maintained and hygienic with COSHH procedures available to staff and materials retained in a locked cupboard. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 23 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 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that they are safe because there are enough competent well trained staff on duty at all times. They can have confidence in the staff because checks have been done to make sure that they are suitable to care for them. EVIDENCE: A requirement was set at the last key inspection that the registered manager must ensure that rotas and time sheets are always available and clearly identify the hours worked by individuals and are signed by both care worker and manager. The registered manager produced rotas that clearly identified the hours worked by individuals. The staff team comprises the registered manager and five other female staff, with minimal use of agency staff. The registered manager works full time and is supported by a deputy manager and four staff that work on part time contracts. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 24 Staff contracts indicate that staff is employed part time for sixteen hours per week. The registered manager told us that although staff had part time contracts some worked full time hour’s and some staff worked more than sixteen hours per week hours as and when required. The staffing roster confirmed that staff works over and above sixteen hours per week thus covering all of the required shifts in the home. The registered manager must review staff contracts ensuring that the contracts accurately reflect the hours worked by staff. The staffing roster indicates that two members of staff support residents in the mornings and one member of staff in the evening and through the night. The registered manager told us that she and the deputy are always on call in the case of an emergency. The deputy manager has been delegated the responsibility of arranging staff training. She produced evidence that staff is receiving good training opportunities. Since the last inspection staff has attended training on health and safety, food hygiene, medication, mental health, mentoring, safeguarding adults and the protection of vulnerable adults, fire safety, moving and handling, infection control, dementia, epilepsy and diabetes. There are dates arranged for staff to attend training on person centred planning, nutrition, the mental capacity act, customer care and first aid in September 2008. Two members of staff have completed NVQ level 2 or above in care and two members of staff are completing NVQ level 2 in care. One member of staff has indicated to the registered manager that she does not wish to complete an NVQ however this member of staff is a retired Registered Nurse. One member of staff told us that she started working in the home two months ago and that she had a one weeks induction before she started. She told us that she has gone on further training. She also told us that the registered manager and the rest of the team have been very supportive and that she had regular supervision. This member of staffs personnel file was examined. The file included a Criminal Record Check and Protection of Vulnerable Adults check, a copy of her passport, two written references, qualifications, an employment contract, a medical questionnaire, a confidentiality statement and a completed application form and interview questions and answers. The registered manager told us that she has recruited another member of staff and showed us a copy of her Criminal Record Check and Protection of Vulnerable Adults check and is awaiting her references, passport and other documentation before she will be permitted to start working in the home. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 25 The registered manager told us that she supervises staff on a regular basis but the she has not always recorded these supervisions. She told us that staff meetings take place on a regular monthly basis and produced the minutes from these meetings. It is recommended that staff receive supervision at least six times a year and these are formally recorded. Information was taken from a number of surveys returned to the Commission from residents and staff. One member of staff commented, “the home caters for all of the residents needs individually, we have very good care plans and staff development training”. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 26 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be sure that their needs are met and wishes are taken into consideration because the home is well managed. The residents can be sure that hey are protected from harm because good health and safety arrangements are in place. EVIDENCE: The registered manager is an experienced registered general nurse with mental health nurse training and has recently completed the Registered Managers Award NVQ level 4. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 27 It was recorded at the last inspection that the registered manager had in partial response to a previous recommendation, upgraded a care worker to a quasi full time assistant manager to assist with the management of the home. It was recommended that this person be properly and formally recognised as a deputy manager as this be appeared to have been on an informal basis. The registered manager told us that this deputy manager was due to retire shortly however the registered manager has recently promoted a support worker to the role of deputy manager. The registered manager and the deputy manager confirmed that a new employment contract was due to be agreed and signed by both parties. The registered manager also needs to review staff contracts ensuring that the contracts accurately reflect the hours worked by staff. Staff should receive formal supervision at least six times a year and these should be formally recorded A requirement was set at previous inspections that the registered manager must ensure that the home develops a system of quality assurance to include an annual development plan for the home, survey and publication of resident’s views, and an annual audit system. Surveys have been regularly conducted with residents their relatives and visitors to the home. Feedback from the surveys was included in the homes annual report 2007/2008, the annual report also referred to complaints, the environment and the last Commission inspection. A quality assurance audit carried out in 2008 considered customer satisfaction, life style choices, person centred planning, promoting health, finance and administration, risk taking, medication, health and safety and staff training. The audit also included an annual development plan for the home. The community psychiatric nurse visiting the home told us “I believe the Tulips has provided a supportive and caring environment in which my client has flourished”. She also told us “the registered manager is brilliant and communication between the home and my team is really good”. Information was taken from a number of surveys returned to the Commission from residents and staff. One resident commented, “sometimes decisions get made by the need to help out which is mutually constructive and helpful to myself and others” and “sometimes I write to the registered manager if there are any ways to improve things around the house, I like to see the property looked after nice for example the patio, hygiene and larder for when and if I cook”. Another resident commented “ the buses are reliable as we are all disabled, on the weekends I might go to church or do crosswords and I see my grand children” Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 28 The registered manager has developed a resident’s charter that refers to independence, discrimination, General Practitioner/medical care, key working, care plans, visitors, support from trained staff and the environment. Residents hold regular monthly meetings, minutes from the meetings indicated that residents are encouraged to be involved in the running of the home and plan social activities and college courses. The registered manager produced a landlords gas safety certificate 20/12/07, portable appliance testing certificate 21/08/07, legionellas testing certificate 21/07/08 and a fire report from an engineer 29/02/08. Records examined indicated that the fire alarm system is checked on a weekly basis, full fire evacuations are carried out and all staff had attended fire safety training. A fire risk assessment was carried out at the home on the 17/04/08. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 29 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 3 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 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 4 X X 3 X Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 30 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA31 Regulation 17 (2) Requirement The registered manager must review staff contracts ensuring that the contracts accurately reflect the hours worked by staff. Timescale for action 30/09/08 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 YA36 Good Practice Recommendations It is recommended that staff receive supervision at least six times a year and these are formally recorded. Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Tulips Care Home, The DS0000058570.V368835.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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