Inspection on 01/02/06 for Tulip Gardens

This inspection was carried out on 1st February 2006.

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

Other inspections for this house

Tulip Gardens 13/08/07

Tulip Gardens 03/11/06

Tulip Gardens 20/07/05

Tulip Gardens 10/11/04

Tulip Gardens 06/07/04

Tulip Gardens 01/03/04

Tulip Gardens 12/09/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Tulip Gardens 5 Court Farm Way Selly Oak Birmingham West Midlands B29 5BW Lead Inspector Brian Reamsbottom Unannounced Inspection 1st February 2006 15:45p Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 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 Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 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. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tulip Gardens Address 5 Court Farm Way Selly Oak Birmingham West Midlands B29 5BW 0121 478 3505 0121 478 3505 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) New Outlook Housing Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years with the exception of one named service user. 20 July 2005 Date of last inspection Brief Description of the Service: Tulip Gardens is a purpose built home for people with a learning disability/sensory impairment. The home is in a residential area on the border of Selly Oak/ Northfield, approximately 2 miles from Northfield town centre. Northfield provides a range of facilities to meet the recreational, social and religious needs of the community. The home is single story with eight single bedrooms. It comprises of two wings, with four bedrooms on each wing. There is a large secluded sensory garden with trees, shrubs and plants chosen for their fragrance, touch or sound. There is parking for emergency vehicles and cars within the grounds. The car park is electronically secured and has CCTV. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report must be read in conjunction with the inspection report of 20 June 2005. The home was inspected unannounced from 15.45 to 19.30. The documentation inspected included the following: Care plans, risk assessments, fire records, medication records, health and safety records, accident book, daily records, complaints and adult protection records, staff personal files and staff training records. Two service users’ and four staff were spoken with. The staff members appeared relaxed and willing to discuss service users’ needs. The inspector thanks service users’, staff and manager for their input to this inspection and for their hospitality. What the service does well: What has improved since the last inspection? Service users’ are more involved in menu planning and are taking part in the weekly shopping for food. The manager and staff have improved the involvement of family and friends in the lives of service users’. This is done by regular telephone contact by staff and relatives. The manager has talked with service users’ about how they want their personal finances dealt with and has passed service users’ views on to senior management. They are waiting for a response. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 7 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 Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Information is available to enable prospective users make an informed choice as to whether they want to live at the home. EVIDENCE: Standard 2 was met at the inspection of 20 June 2005. The two service users’ files inspected had a statement of terms and conditions with home. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Service Users assessed needs and goals are reflected in their individual care plans so that staff know how to support each individual. Service users’ are consulted on, and participate, in many aspects of life in the home to ensure good outcomes for them. Risks are well managed to ensure people are safe in the home. EVIDENCE: Two service users’ care plans were inspected. One of the plans had been reviewed and updated since the last inspection. The other is in the process of being reviewed. Since the last inspection there has been a new manager appointed. The manager told the inspector that all service users’ care plans, risk assessments and their likes and dislikes are being reviewed and updated. The plan that had been reviewed clearly states how the needs and wishes of the service user are to be met. Service users should be given a copy of their care plan in an appropriate format. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 10 The manger informed that inspector that discussions have taken place with service users’ in respect of the administration of their personal finances. This was confirmed in speaking with a service user. The manager went on to say that senior management is now have the information from service users’ and are waiting for action. Risk assessments are in place and are presently under review. The risk assessment record for one service user is about the use of ‘bed rails’. The record is more about the manufacture of the rails and their safety. The risk assessment must clearly show that the ‘bed rails’ are appropriate to meet the needs and safety of the service user. A new risk assessment must be completed as a priority. All reports and records must be signed. The signature must include the surname of the author. The new manager is actively arranging monthly meetings for key workers enabling them to share knowledge in meeting the needs of service users.’ Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Service users’ are part of the local community and participate in appropriate leisure activities. Arrangements are in place to support residents to have appropriate family relationships. Service users’ choose what they eat and enjoy their meals and mealtimes. EVIDENCE: Standards 12, 13, 15, 16 and 17 were met at the inspection of 20 June 2006. Service users’ continue to make use of the facilities in the community. The activities that each service user takes part in is recorded on their activity sheets. However, one of the activity sheets inspected had not been updated for over a year. This must be done with the involvement of the service user. There is evidence that additional activities are being offered to service users’. Halesowen College comes into the home each Friday for four hours to help Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 12 improve service users’ skills in cooking. Other activities on offer are: computer at two local colleges, swimming, music therapy, woodwork and cooking. Service users’ have access to an independent advocacy service. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The medication management is good ensuring service users receive medication as prescribed. Systems are in place to ensure that service users receive the care they need. EVIDENCE: Health Action Plans are in place and have had improvements made. However, further improvements are required. The plans must include the involvement of service users’ in identifying their needs and how they are to be met and by whom. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The complaints and adult protection procedures available ensure that service users are protected from harm. EVIDENCE: Standards 22 and 23 were met at the inspection of 20 June 2006 and were not inspected at this visit. The manager stated that there have been no complaints received since the last inspection. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home was clean, warm and fit for its purpose and provides service users with a safe, homely and comfortable environment. EVIDENCE: Standards 24, 27 and 30 were met at the inspection of 20 June 2005 and were not inspected at this visit. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 The homes recruitment procedure is robust and ensures service users are protected from harm. Staff have received training to enable them meet service users needs. EVIDENCE: Standards 34 and 35 were met at the inspection of 20 June 2005 and have not been inspected at this visit. Interactions between staff and service users’ were observed. These were positive and service users appeared happy and comfortable in the presence of staff. Two members of staff spoken with were motivated and committed to meeting the needs of service users’. Two service users’ said that they liked the staff and they are friendly and helpful. The organisation is committed to having a well trained staff group. There are records showing that all statutory training has recently been updated. The staff team have and are completing NVQ levels 2 and 3 training enabling them to meet the needs of service users’. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 The home is well managed to promote the health and safety of service users. EVIDENCE: Standard 42 was met at the inspection of 20 June 2005 and was not inspected at this visit. Standard 39 has now been met and is on file. There is a new manager in post; she was formerly the deputy manager. The inspector discussed the need to complete her application for manager as soon as possible, to enable a ‘fit person’ interview. The manager is in the process of completing her Registered Managers Award. Good use is made of the communication book. It contained no personal information on service users’. Members of staff are directed to the appropriate section of service user files from entries in the communication book. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 18 The various forms in use have printed headings, however, if the appropriate form is not available staff are crossing out the headings and hand writing the heading that they want. This practice must cease, it does not present a professional approach. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 19 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X 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 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 X X 3 X 3 X X X X Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 Timescale for action 02/02/06 2 YA19 A risk assessment for the use of ‘bed rails’ must be completed to ensure the safety of the service user. 12(1)(a)(2) Service users’ must be involved in the Health Action Plan. Identifying their needs and how they are to be met and by whom. 31/03/06 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 2 Refer to Standard YA41 YA41 Good Practice Recommendations Better recording systems should be introduced. All reports must be signed by the author and include the surname in the signature. Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tulip Gardens DS0000017161.V281499.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!