Inspection on 05/10/07 for Tulips Care Home, The

This inspection was carried out on 5th October 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 5 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

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Tulips Care Home, The 326 Hither Green Lane Hither Green London SE13 6TS Lead Inspector Keith Izzard Unannounced Inspection 5th October 11:00 Tulips Care Home, The DS0000058570.V340280.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.V340280.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.V340280.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 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.V340280.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 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. Current service users are young and the home’s philosophy is to encourage participation in the day-to-day running of the home and in the local community. The staff complement comprises the manager and four other female full time staff, with minimal use of agency staff. The staff team is now consolidated. 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 recent CSCI report is displayed prominently in the entrance area to the home. The homes fees are set at £600.00 per week, for all service users, 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.V340280.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over one day. The registered manager was present and co-operated fully and constructively during the inspection in conjunction with a care worker on duty. The Inspector interviewed the manager and one staff member and spoke with three residents. Many of the requirements had been met and there was evidence of good improvements being made to recruitment practices, care planning and in the environment of the home. Several questionnaires were sent to involved professionals connected with the home to ascertain their views on the suitability of the home and current performance. Regrettably, only one was returned prior to publication of this report, this was very favourable and indicated that improvements had been made. Questionnaires returned by residents themselves were very complimentary about the service provided. The inspection included a tour of the home, an examination of records in respect of residents’ care plans and building maintenance records, and staffing records regarding recruitment and training and interviewing three of three of the four residents. There were no vacancies within the home. What the service does well: The home provides a homely environment, which gives good potential for ordinary living. A very positive comment was received from one care manager who returned a questionnaire to CSCI and from all the residents. There is a welcoming approach to residents having visitors, and one resident stated that she had the opportunity to visit the home before moving in and was given a choice about where she was placed, she said that her family visit regularly, and can visit at any time, and the staff members are friendly and helpful. The residents have daily contact with the manager and found her very approachable. Staff members were seen to be caring and professional in their approach to residents. Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 6 The home is kept clean and well maintained. Food is good and residents are encouraged to be involved in preparing their meals and have full access to the kitchen. The management of the home responds well to suggestions as to how to improve the home and the service offered. What has improved since the last inspection? What they could do better: The 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. The manager must ensure that both she and the staff members sign the time sheets and rotas to evidence their attendance on duty for the required period of time. The rota and time sheets must specifically require attendance to be signed and dated for each shift completed. The manager needs to complete her NVQ Level 4 training and to consider officially appointing an assistant manager to benefit to the running of the home and allow for some delegation of duties. This has been an outstanding matter for compliance for some time now and must be addressed. The manager must further develop an annual Quality Audit and use the results of this, and other systems such as service users surveys, to put in place a Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 7 development plan for the home. This also has been an outstanding matter for compliance for some time now and must be addressed. Several recommendations were also made: The manager should make every effort to obtain an advocate for the resident who has no family to support her. The manager should make every effort to obtain an advocate for the resident who has no family to support her. The manager should make every effort to obtain an advocate for the resident who has no family to support her. The manager should ensure that the training and development needs of the staff team as a whole are identified and form part of the annual development plan for 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. Tulips Care Home, The DS0000058570.V340280.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.V340280.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to their admission to ensure that their needs can be met. EVIDENCE: Standard 2 The personal care files of two residents, one new and one who was a longer term resident of the home. The care files included detailed referrals comprising assessments completed as part of the care management process and reports from professionals such as psychiatrists, and other therapists. Both the files included a care plan and the provider stated that the care planning and risk assessment process starts before admission to the home and are now planned approximately a month beforehand. Residents had clearly been involved in the setting up of their care plans and had signed them. Goals for development had been clearly identified and the process by which care staff members would achieve them and reviews of care clearly scheduled with input from both Community Psychiatric Nurses and Care Managers. Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 10 Tulips Care Home, The DS0000058570.V340280.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed needs of residents are recorded in their care plans and regularly reviewed and updated. Residents in the Home are treated as individuals, encouraged to lead an independent lifestyle and their care plans reflect their individual needs and wishes. EVIDENCE: Standard 6 A requirement was made at the previous inspection that the care provided by staff members within the home, would be reviewed regularly by care managers or community psychiatric nurses from the placing authority. Evidence was seen of this on all four care files seen that these reviews had been conducted Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 12 appropriately and in accordance with the Standard. However, it was noted that not all residents’ care plans and reviews had been signed by both the manager and the resident, this must occur and handover session notes signed by care workers. See Requirement 1 Standard 7 Residents have opportunities to affect decision-making in the home. There are regular monthly meetings and service users are encouraged to express their views at any time. Two residents spoken to said that they would feel able to tell the manager or any other staff member if they were unhappy about anything in the house, or their care. In addition, the staff formally request residents to complete questionnaires about their views on the quality of service provided, and copies of these questionnaires were seen on the case files that were examined and showed a high degree of satisfaction with the service provided by the home. A previous requirement that was made that the manager provides a written agreement of their being joint signatories to one residents banks account has now been resolved satisfactorily. Standard 9 Risk assessments were on file, and in individual cases had been updated to record where assessed risks may have increased or reduced over time and staff members promote independence as much as possible. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of service users. Evidence was available from the service user’s records examined and from discussion with both service users interviewed that residents are enabled to express choice in whatever they do. Tulips Care Home, The DS0000058570.V340280.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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home enjoy a comfortable and stimulating lifestyle, where individual choice is respected and encouragement given to achieving life skills. Personal and family relationships are encouraged and promoted. A healthy diet is provided and meals are provided at times which suit service users. EVIDENCE: Standards 12-16 The home has produced improved care plans that now record what activities have taken place both within the home and in the community. Two residents said that they go out independently and regularly to a range of activities such as shopping, the pub, and local theatre, and have regular Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 14 contact with family friends. One resident described a range of activities which she is supported to attend such as embroidery classes, cookery classes, attending shows at the Lewisham Theatre on a regular basis, as well as helping out in the home in the kitchen and keeping her room clean and tidy. Another resident said she had settled in well to the home and felt she could ask the manager and staff for any support she needed. Each service user has available a written weekly plans for activities, to act as a reminder for themselves and for the benefit of staff members keeping track. Information about activities done with service users is recorded on handover notes for each service user. The home has a policy of encouraging and supporting service users to maintain contact with family and friends and in supporting personal relationships. One resident has no family and the manager is trying to obtain an advocate, although the manager stated that this resource is in short supply locally. See Recommendation 1 There are good working relationships developing between staff and residents two of whom stated that staff members are easy to talk to and are always available to offer help, when required. There are no barriers in the home between staff and residents all of whom have their own keys to their home and individual rooms and staff members are respectful of their right to privacy. It is expected that service users will engage in all domestic activities and this is specified in the home’s service user guide. The specific tasks that individual service users will take part in are reflected in their individual plans based on their personal motivation aptitudes and risk assessed in respect of health and safety considerations. Standard 17 Three residents interviewed said that the food in the home is good and there are a variety of things they like to eat available. The menus are dated and planned on a rolling menu system showing weeks 1 to 4. They also said they were involved in shopping and were offered a choice in what they ate. 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. One resident was observed having a meal later than the others , as this was her preference and another resident and a member of staff had joined her with a cup of tea making it a more social occasion, rather than sitting on here own. Tulips Care Home, The DS0000058570.V340280.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive flexible personal support. The physical and mental healthcare needs of service users were met. The medication system for the home was well organised and recorded. EVIDENCE: Standard 18 The home has comprehensive care plans for all service users, and these include written guidance to staff members to ensure that residents’ independence is protected and respected. All personal care support provided is same-gender care The home is not registered to provide nursing care but residents are given assistance to maintain their own personal care, largely via prompting, where Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 16 necessary in respect of their personal hygiene and to keep their clothes clean and their rooms tidy. Standard 19 Healthcare needs are given high importance at the Home. Residents are supported to take responsibility for their own healthcare, though are supported to attend appointments where necessary. Evidence of various appointments being made with a variety of health and social service professionals was available on both the individual care files and the daily diary notes examined by the Inspector. Residents weight was monitored regularly and residents are encouraged to consume their food in a health conscious way, paying attention to any need for promoting weight gain or loss as necessary, or appropriate dietary requirements. There have been not been any significant incidents requiring notification under Regulation 37 to CSCI, since the last inspection of the home. Standard 20 The medication system was examined and was appropriately organised; medication was stored within individual locked cabinets in residents’ own rooms and quantities and dosage of medication tallied with the MAR sheets examined for two residents who were case tracked. However, it was noted that one medicine cabinet was not securely fixed to the wall and to meet the standard must be affixed with a “rawl-bolt”. It was also noted that one entry on the MAR sheet for a resident was handwritten but had not been countersigned in order to avoid mistakes. See Requirement 2 The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist, although, it was suggested that the Pharmacist be requested to do periodic medication audits for the home. Tulips Care Home, The DS0000058570.V340280.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. Residents feel that their views are listened to and are acted on, and the home’s written policy/ procedures ensure that service users will be protected from abuse, neglect or self-harm. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. No complaints had been received directly by the Commission or by the home since the previous inspection. All residents have the capacity to raise concerns and those spoken to by the Inspector both indicated that they were very happy within the home and actually had no complaints. The Inspector advised that complaints that might be received should be separated in respect of their outcomes to reflect whether they were substantiated, or not, or partially substantiated. Standard 23 Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 18 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 or the Commission since the last inspection. The home did have a copy of the London Borough of Lewisham Safeguarding Adults Procedures and it was recommended to the manager that it is read by all staff members, and that they sign to say they have read and understood the procedures. See Recommendation 2 Risk assessments regarding service users managing their own finances have been updated. 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 latter could be filed better and we recommended that these be retained in a separate lockable cabinet, as the safe was very small. See Recommendation 3 Tulips Care Home, The DS0000058570.V340280.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is generally homely, comfortable and safe. The Home is bright, spacious and welcoming. Bedrooms are personalised by the individual resident. The home was clean and generally well maintained. EVIDENCE: Standard 24 The home was clean, bright and comfortable. The Home is well suited for its purpose. There is a range of communal space including a large and comfortable lounge, a kitchen/dining room and a small level garden mainly lawn with shrub borders with, a level patio and garden furniture nearer the Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 20 house. Some new planting had been done in the garden and it appeared attractive in layout. The three bedrooms seen by the Inspector were personalised by the individual residents, and there was evidence of residents’ interests and personal possessions in each of the rooms seen. Bedrooms were spacious and had facilities available for residents’ personal storage. The home is generally well maintained and kept clean and safe. There is sufficient light and ventilation and furnishings are adequate. The 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, when necessary. Standard 30 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 COSH procedures available to staff and materials retained in a locked cupboard. Tulips Care Home, The DS0000058570.V340280.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- 35 Quality in this outcome area is good. Residents are supported by competent and qualified staff and given adequate protection by the home’s recruitment policy and practices. Staffing hours must be recorded and signed for on readily available rotas. The training programme for staff members ensures residents’ needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 32 This is a small family business and the manager and staff members are on the rota week on week, so there is consistency for the residents. Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 22 From observations made of care worker and manager practice and the evidence of training provided for staff we felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite skills, attitudes and characteristics necessary to adequately support residents. Staff members were observed to be respectful and caring in the way they were relating to residents. It was equally evident that residents were content within their environment and responding positively to any staff interventions. The home employs staff experienced in providing care for this service user group. Three out of the four care staff are trained to NVQ level 2/3 in care and the other person will have completed by early next year. The residents cultural backgrounds, however, are not reflected in the staffing provided but the manager has taken some measures to address this issue by providing all staff members with Management of Diversity training, and by being sensitive to this issue when employing new staff. Standard 33 At the previous inspection an immediate requirement was made to ensure that two staff members are on duty during day time hours, this is now met and evidence of this was available of this on the staffing rotas examined. However, the manager must ensure that both she and the staff members sign the time sheets and rotas to evidence their attendance on duty for the required period of time. The rota and time sheets must specifically require attendance to be signed and dated for each shift completed. See Requirement 3 Standard 34 There was a requirement made at the inspection before last and also at the last inspection for the home, to ensure that there is a consistent and stable staff team who are in possession of a statement of their terms and conditions of employment. This is now met, as evidence of these documents, having been provided, was seen on the staffing files examined. One new member of staff had been appointed since the previous inspection. The personal file of this new staff member was seen and found to comprehensively meet the recruitment requirements of this Standard. Standard 35 At this inspection the Inspector was informed that three of the care staff have achieved NVQ level 2 and that the new member of staff is completing her NVQ level 2 within the next few months. The manager provided evidence of the training plan for the year 2006-2007 and this was comprehensive. All staff members had received induction and foundation training and had, in place, an individual training and development plan, however an overall training plan, for Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 23 the staff team as a whole, should be developed to identify any shortfalls across the staff group. See Recommendation 4 Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run but improvements are still required in management qualification and formal delegation. Quality assurance mechanisms were being developed and surveys of residents conducted, these must be extended to include relatives and professionals and published. Health and safety matters were well attended to. EVIDENCE: Standard 37 Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 25 The registered manager is an experienced registered general nurse with mental health nurse training, but does not have a depth of experience in management and does not currently hold the required NVQ level four. At the previous inspection it was reported that the manager had commenced this qualification, however, this was deferred and only commenced recently. As this requirement has now been the subject of two restated requirements it is essential that the restated requirement is complied with. See Restated Requirement 4 The manager has, 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 is recommended that this person be properly and formally recognised as a deputy as this be appears to have been organised on an informal basis. See Recommendation 5 Standard 39 The manager had partially responded to a previous requirement to develop a system of quality assurance within an annual development plan for the home. Surveys have been regularly conducted with residents but surveys must also be sent to any involved relatives or advocates and also to involved professionals with the home. The results of the surveys must be made known to residents and published for anyone to see and a copy specifically sent to CSCI. See Restated Requirement 5 Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. A number of areas to do with health and safety were picked at random and checked against the pre inspection questionnaire (AQAA), in respect of routine checks such as fire drills and other areas requiring maintenance checks. This information provided, was accurately recorded, verified, and in accordance with that submitted by the manager to the CSCI. Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 26 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 (2) Requirement Timescale for action 01/12/07 2. YA20 13 3 YA33 18 a 4 YA37 9.2 (b, I) 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. The Registered manager must 01/12/07 ensure that all medicine cabinets are securely affixed to walls with” rawl bolts”. Also any handwritten entries on MAR sheets are countersigned to avoid mistakes being made. The Registered manager must 01/12/07 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 must 31/10/07 complete an NVQ level 4 course in management and care. This is a repeat of a previous requirement, Timescale 31/10/06 &31/10/07, not met, and now revised. Continued failure to meet this requirement may result in enforcement action DS0000058570.V340280.R01.S.doc Version 5.2 Tulips Care Home, The Page 28 5. YA39 24 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 service users views, and an Annual Audit system. This is a repeat of a previous requirement, Timescale 31/01/06, 31/03/06, and 31/07/06 31/07/07 now partially met. Timescale has now been revised. 01/02/08 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 2 3 4. Refer to Standard YA20 YA23 YA23 YA35 Good Practice Recommendations The manager should make every effort to obtain an advocate for the resident who has no family to support her. The manager should ensure that all staff members sign to say they have read and understood the safeguarding Adults procedures. The manager should relocate the written records/receipts pertaining to residents’ personal monies to allow better use of the safe. The manager should ensure that the training and development needs of the staff team as a whole are identified and form part of the annual development plan for the home. The registered provider and manager should consider the official and formal appointment of a permanent assistant team manager. 5 YA37 Tulips Care Home, The DS0000058570.V340280.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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.V340280.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. 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