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

This inspection was carried out on 7th October 2005.

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 no outstanding requirements from the previous inspection report, but made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tulips Care Home, The 05/10/07

Tulips Care Home, The 11/05/06

Tulips Care Home, The 09/12/05

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 Sean Healy Unannounced Inspection 7th October 2005 10:00 Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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.V258094.R01.S.doc Version 5.0 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.V258094.R01.S.doc Version 5.0 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) 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.V258094.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection 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. Currently there are three service users in residence. 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 lots of on road parking nearby. All residents each 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, which is in the process of development and is accessible from the hallway. The home is privately run, owned by the registered manager, and first opened in March 2005. Current service users are young and the homes philosophy is to encourage participation in the day-to-day running of the home and in the local community. Staffing is provided by one female manager and currently three female staff. The staff team is in the developmental stage. Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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 home’s registered manager was present and co-operated during the inspection. The inspector interviewed one staff member and spoke with two service users. These discussions were brief due to the nature of activities on the day. There were a number of issues of serious concern identified regarding staffing, which required contacting three social workers to advise that the home would need to be staffed temporarily by agency staff and to seek their views on the quality of support provided. The inspection included a tour of the home and examination of records on care plans and building maintenance records, and staff records regarding recruitment and supervision. The registered manager responded in a positive and active manner regarding concerns raised and made commitments for immediate improvements. The manager agreed not to take further referrals until the homes staffing and management had stabilised. Two immediate requirements were made regarding staff recruitment procedures and staffing levels. What the service does well: What has improved since the last inspection? What they could do better: The home needs to get better information on service users’ care needs from social service and mental health professionals and use this information to develop better care plans. At the moment the assessments have been carried out by the manager of the home, and there is little information from social services on service user files. Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 6 Service users need to be given copies of their contracts and these should not be kept outside of the home. At the moment some are being kept at the owner’s own home and none of the service users held copies of their own. Service users’ care plans need to be better organised and state more clearly what service users want to do and how this will be made to happen. Risk assessments need to be improved to include better directions for staff and service users about what to do to manage risky situations. The home’s office area is an annexe to the kitchen, which makes having a meal less private and causes some risk about confidentiality of service users’ information; the owner should consider moving this to another area in the home. Although meals and menus are planned the homes record of what was eaten needs to be better to ensure that they show that service users have a balanced and healthy diet. There needs to be a better description of individual service users’ personal care support needs to make sure that service users get the right level of support. The way medication coming into the home is recorded, and the way checks are carried out about medication needs to be improved to make sure that service users are protected. The medication cabinet lock needs to be fixed. The staff and manager need to have training in how to protect service users from abuse and risk-assessments need to be done so they are fully safeguarded from financial abuse. There has to be a lot of improvement in how the owner and manager carry out checks on staff before they start working at the home, such as making sure police checks are done and references are good, in order to make sure that service users are protected from abuse. Staff training plans need to be put in place, and plans made to make sure that the staff and manager are going to get the appropriate qualifications. Service users need to be asked about their views on how the home is run and managed and plans put in place for taking these views into consideration to improve the service provided. Some work needs to be done to plan better for the home maintenance, to make sure the home is always comfortable and safe. 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. Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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 Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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): 1,2,4 and 5 Prospective service users have the information they need to make an informed choice about where they live, but current and prospective service users’ needs are not fully assessed which can mean important needs will not be met. Prospective service users have an opportunity to visit the home and to assess whether it is suitable for them. Service users are not in possession of contracts of terms and conditions, and though they have been written, they are not adequate in details, which may lead to denial of rights. EVIDENCE: On inspection there was no evidence of any service users having Social Services assessments or CPA assessments on file, and the manager confirmed that these had not been provided. The manager had carried out assessments of her own but these were not informed properly by Community Care Assessments or by mental health CPA assessments. This must be addressed to ensure care provided is effective and safe. (Refer to Requirements YA2) There was no good written evidence that three/six month reviews had taken place. It was described by the manager that it is the home’s policy to carry out these reviews and this is also expected as good practice to ensure an informed choice is being made regarding the homes suitability. The manager needs to write to social services to prompt these reviews to happen for all service users. (Refer to Requirements YA 2) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 9 At the time of inspection the manager said that service users’ contracts were in place but were kept at her other house and that service users did not have a copy. It is not acceptable to store these records at the manager’s private dwelling, and service users must be given a copy of these contracts. The manager said the contracts needed to be updated to include rooms to be occupied, arrangements for care and support reviews and would check that all other details required by Standard 5 are included. (Refer to Requirements YA5) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 10 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): 6,9 and 10 Service users cannot be sure that all of their assessed needs and personal goals are reflected in their individual plan, which may result in important needs not being addressed. Service users are supported to take risks but action to minimise hazards needs to be improved otherwise risk to service users and staff may remain high. Service users may not always feel that information about them is handled appropriately which may result in unnecessary worry or damage trust. EVIDENCE: None of the three service users files contained Community Care Assessments or Care Programme approach risk assessments, although all service users were social services referrals and some were on the CPA. The manager had carried out her own assessments and produced care plans which had some good detail but which were poor in action detail and review dates and could not be deemed as fully inclusive without being based on assessments from the referring agencies. It was noted that service users individual plans were based only on information compiled by the manager, and that some of the wording referred to the service users’ “problem” rather than “support needed” or “goal”. Action for achieving goals often read as an outcome rather that action describing what to do and who would do it. (Refer to Requirements YA6) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 11 On inspection of service users’ files it was evident that risk assessments were in place for each service user but these had not been based on social services’ or CPA assessments, though it was clear that some service users were or had been subject to the Care Programme Approach and had CPN involvement. Dates on assessments were confusing, and information did not include who was involved, or any clear guidance for staff in management of significant risk, though one service user had a history of threatening behaviour using a knife. (Refer to Requirements YA9) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 12 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): 15 and 17 Service users are supported to maintain relationships with family and friends and to have full personal relationships. Service users may be offered a healthy diet but the home’s records of food eaten do not allow an accurate judgement to be made. EVIDENCE: The home’s policy on visitors welcomes maintaining links with family and friends and places no restriction on visitors who have been invited by service users. One service user was in the process of entertaining a guest and planned to go out later. She said she was happy with the home’s support. On inspection, the menus were undated on planned on a rolling menu system showing weeks 1 to 4. The manager described how service users were involved in shopping and were offered a choice in what they ate, and one service user confirmed she was involved and that the food is good. There was no evidence of any changes in recordings on the menu to reflect what was actually eaten by individual service users, and little evidence of service user involvement in cooking. (Refer to Requirements YA17) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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): 18 and 20 Service users’ plans do not yet reflect the way they prefer to receive personal care/support which may result in disempowerment. Service users do not retain control of their own medication, where appropriate, and are not fully protected by the home’s procedures and practices, which may result in denial of rights and loss of medication. EVIDENCE: The manager explained that some service users are totally independent in personal care while at least one requires some prompting. Care plans or guidance do not reflect what level of prompting is required. (Refer to Requirements YA 18) The home has an adequate medication policy and takes responsibility for administration of medication for all current service users. The manager explained that this was by agreement with service users and their social workers. However, this agreement was not recorded or signed by the service users or the registered manager. The home needs to ensure that when service users medication if fully managed by the home that this is recorded and signed for in relevant care plans (Refer to Requirements YA 20). The manager currently takes responsibility for administering medication, and records of medication given are well maintained. On inspection, the medication cabinet lock was found to be broken, and given it’s close proximity to the kitchen area, Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 14 presented a serious risk. The manager moved the medication to a locked filing cabinet at the inspector’s request, as an interim measure. Incoming medication records showed numbers of “boxes” of medication received rather than quantities and was not being regularly checked by the manager. There was no record of when the last check was done by the manager, who said it had been some months since last counted. (Refer to Requirements YA 20) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 15 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): 22 and 23 Service users feel that their views are listened to and are acted on; however, staff training and awareness does not yet ensure that service users will be protected from abuse, neglect or self-harm, which currently presents a hazard for service users. EVIDENCE: The home’s manager is a trained general and mental health nurse, and maintains a high level of presence within the home which reduces risk of likelihood of abuse and allows staff to regularly have access to her experience and advice. The service users and social workers spoken to confirmed that this is the case. The manager and staff have not had any training in adult protection, and there was little understanding of this policy demonstrated by staff interviewed. (Refer to Requirements YA23) The registered manager commented that all service users independently manage their own finances but that she is concerned regarding one service user being vulnerable to abuse from people outside of the home. Though she said that social services have directed her to maintain this independence, as yet these concerns have not been formally documented to protect staff and service users. (Refer to Requirements YA23) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 16 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): 24.25,27 and 30 The home’s design and layout does not fully ensure that service users live in a homely, comfortable and safe environment, which can lead to service users not being at ease in their home. Individual bedrooms suit the needs and lifestyles of current service users, and bathrooms and toilets provide sufficient privacy and comfort. The home is clean hygienic and well maintained. EVIDENCE: The home has a bathroom and toilet on the first floor and a ground floor shower room and toilet, which meet minimum requirements for toilet and washroom facilities. None of these facilities are wheelchair accessible but current service users are fully mobile. However, access to the shower room involves going through the laundry area, which is visible from the kitchen/dining room. The shower room is currently small making changing difficult. The home’s management should give consideration make adjustments to the design of the shower-room to improve service users comfort. (Refer to Recommendations YA24) The home’s office space is located in a small annexe to the kitchen, which makes it difficult for service users to have privacy while eating and cooking without being overseen and overheard by staff seated in the office. Similarly it is difficult to protect service user information adequately as the main phone, Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 17 fax, computer and filing system is also located in this office. Requirements YA 24) (Refer to The home has had the London Fire Service visit the home to carry out an inspection. A report was provided to show the premises to be safe regarding hazards from fire. The home has an integrated fire alarm system and is fitted throughout with smoke sensors, fire doors and fire extinguishers. The home is currently in a good state of repair but does not currently have a planned system or programme for maintenance and renewal, although a repairs book is being maintained. (Refer to recommendations YA24) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 18 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): 32,33,34and 35 Service users are not currently supported by competent and qualified staff working as an effective team, which will result in poor service delivery if not addressed. Service users are not currently adequately protected by the home’s recruitment policy and practices, placing service users potentially at risk, and the home’s staff-training programme does not yet ensure service users’ needs will always be met. EVIDENCE: The area of staff recruitment and training, and staffing levels are a cause for serious concern, and are currently placing service users in a situation of potentially high risk of abuse, and of not receiving enough staff support to meet assessed needs. These matters were a cause for the manager to be required to take immediate action to protect service users on the day of the inspection and to commit to not accepting any further referrals to the home until the following issues have been addressed and the staffing and management of the home has been brought up to a level of acceptable stability and safety. However, the homes manager did spend unusually long hours in the home and was described by three separate social workers as having provided a good service and being very hands on in the running of the home. This has gone some way to re-dressing the issue of service user safety in the past, but has had obvious effects on the ability to carry out very necessary management and supervisory duties. The registered manager agreed that this was the case and took very seriously the issues and concerns Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 19 raised and made commitments to take prompt action to resolve the more serious concerns quickly: None of the support staff currently employed had attained NVQ level 2/3, and plans were not yet in place to do so. (Refer to Requirements YA32) Service users assessments did not reflect individual support hours needed, and the homes rota did not reflect the total hours needed for all service users. The manager described the home as providing two staff for service user support between 8am and 10pm and one sleepover staff at night. However, the staff rota did not reflect this; there were only three other staff on the rota apart from the manager, and one of these was doing sleepovers every night. The manager explained that she herself covered any shortcomings in staff available and that one member of staff was acting as a live in support tenant, and therefore covered most of the sleepover duties apart from those covered by the manager herself. After discussion it was agreed that this was not a feasible arrangement, and that staffing levels must be defined clearly and alternative arrangements must be made to provide more robust staffing including at nighttime. An immediate requirement was made for the home to provide two staff between 8am and 10 pm, and for staffing levels to be reflected properly in the homes duty rota. (Refer to Immediate Requirements YA33) At inspection, the staff rota showed a total of four staff including the manager providing 24-hour support for a home registered for four service users. The manager said that there should always be two staff working during daytime hours and one staff sleeping over at night. The rota was not specific regarding the hours being worked by each member of staff, and from discussion it was clear that the manager does a substantial number of unrecorded additional hours to bolster staff support hours. The night support was described as being mainly provided by one member of staff, who was being provided with sleeping accommodation within the home. No other staff do sleepover duties and the manager fills in any gaps when this member of staff is out or away from the home. There was no agreement in place with service users that this arrangement was acceptable. This arrangement does not provide adequate support for service users and puts a lot of pressure on the home’s manager/owner. (Refer to Requirements YA33) Two of the three staff had been employed by the home for approximately two months, but had not yet been CRB checked by the home or provided any other previous CRB check results. One of these staff was also doing sleepovers independently at the home almost every night. A third member of staff had been CRB checked but the manager explained that she had serious concerns regarding issues arising from this, and felt that she should not be maintained on the staff team. The home did not have two written references for any of the staff though the manager said she had some verbal ones over the phone. An immediate requirement was made for the manager to ensure the home was staffed only by staff for whom acceptable CRB checks had been carried out, Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 20 and for whom acceptable references had been taken up (Refer to Immediate Requirements YA34). The manager took immediate steps to introduce regular agency staff and ensured that the two staff that had not yet been CRB checked did not work without management supervision in the home and did not engage in personal care support. The manager agreed that given the current staffing problems the home would not accept any further referrals until staffing had stabilised, and any change to this would be by prior agreement with CSCI. (Refer to Requirements YA 33) The manager agreed to discontinue the current arrangements for one member of staff to cover sleepovers as a live in support tenant, and not to re-instate it unless it has been formally agreed by service users and their representatives, and had been written into the homes Service User Guide. (Refer to Requirements YA 33) The manager confirmed that the home does not yet have staff training and development plans in place. (Refer to Requirements YA35) Staff records did not reflect good adherence to methodically inducting staff in line with recommended good practice such as TOPPS or LDAF induction frameworks. At inspection it was not possible to fully check this with staff and individual staff records were inconsistent. (Refer to Requirements YA35) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 21 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): The home’s management is not yet functioning to the degree of effectiveness required to enable the home to run well, which may place service users at risk. Service users cannot yet be confident that their views underpin all self monitoring, review and development by the home, denying them opportunities for inclusion. Service users’ health, safety and welfare are not always promoted and protected by the home, which may place them at risk in their home and local community. EVIDENCE: 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 an NVQ level four qualifications. Given the number of number of areas of management oversight described in this report it is fundamental to the success of this project that the registered manager undergoes management training to ensure that she has the necessary skills to plan support for service users and staff. Feedback from three social workers described the manager as hard working and as having Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 22 been successful in providing a service for their service users referred. (Refer to Requirements YA37) The registered manager is due to be off work for a period of maternity leave very soon and as yet there has been no alternative manager identified to act in her absence. Given the range and volume of management issues which need to be addressed the manager agreed verbally to employ an experienced agency manager for a period of at least 6 months to provide cover during her absence and support after her return. (Refer to Requirements YA37) The home has now operated for six months and does not have any adequate systems yet for Quality Assurance or consultation with service users in place. (Refer to Requirements YA 39) The home’s management need to address the following issues: 1.The home needs to have a hot water regulator installed for the shower and bath and to sinks in both of these rooms. 2. The manager needs to carry out risk assessments for each service user regarding access to hot water in the kitchen sink. 3. The manager needs to install a window restrictor to the window of one of the service user’s bedrooms on the first floor. 4. The home must carry out fire evacuation drills at least every three months. 5. The home must keep an accurate record of visitors to the home; the current visitors book reflects gaps in recordings for several months. (Refer to Requirements YA42) Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 1 x 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 1 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 1 1 1 1 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tulips Care Home, The Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x DS0000058570.V258094.R01.S.doc Version 5.0 Page 24 NA 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 YA2 Regulation 14.1 and 2 Requirement Timescale for action 31/10/05 2 YA2 14.1 and 2 3 YA5 17.1 a,b Sc. 3.4 The registered manager must ensure that all service users are admitted only on the basis of a full assessment undertaken by people trained to do so, with the involvement of the service users and her representatives. The manager must ensure that all current service users Social Services assessments and where appropriate CPA assessments are obtained and used to inform support plans. In accordance with the homes 30/11/05 moving in policy, the registered manager must ensure that all of the service users’ placements and assessments are reviewed and revised to include dates of review, and stating who has been involved in reviews. The registered manager must 30/11/05 ensure that all service users are in possession of a written and costed contract, stating the terms and conditions between the home and each service user, in accordance with Standard 5 of the National Minimum Standards. The manager must DS0000058570.V258094.R01.S.doc Version 5.0 Tulips Care Home, The Page 25 4 YA6 15.1 and 2 5 YA9 13.4 (b,c) 6 YA17 12.1(a) 7 YA18 15.1and 2 8 YA20 13.2 further ensure that these have been signed by the service user and the homes manager, and that they are stored in a secure place at the home. The registered manager must review all service users Care/Support Plans to ensure that they are based on Social Services and CPA assessments, and that plans are positively worded, and clearly identify the individual areas of support required and action to be taken. The registered manager must ensure that that risk assessments for all service users are reviewed and revised to include any relevant information from Social Services and CPA assessments. These must be reviewed at least every 6 months. In doing so the risk assessments must be clearly dated, showing who was involved and risk assessments showing medium or high levels of risk must be supported by written guidance for staff in how to support service users. Such guidance must be kept in a place easily available to staff and individual service users. The registered manager must ensure that records of food eaten are maintained and dated, showing any changes to planned menus. Menus must be flexible and service users must be encouraged to help plan and prepare their own meals. The registered manager must ensure that all service users personal care/support needs are reflected in their care plans in order to maintain individual levels of independence. The registered manager must DS0000058570.V258094.R01.S.doc 30/11/05 30/11/05 31/10/05 30/11/05 31/10/05 Page 26 Tulips Care Home, The Version 5.0 9 YA20 17.1 (a&b) 10 YA23 18 (c) 11 YA23 12.3 12 YA24 12.4 (a) & 23.2 13 YA32 18 (c) ensure that all medication is kept in a safe secure place and that records of incoming medication are appropriately maintained. In doing this, the manager must ensure that the lock on the current medication cabinet is fixed, and that the system for recording incoming medication shows detail of the number of tablets received, and a regular weekly system for checking the medication administration and recording system. The registered manager must ensure that service users consent to medication is obtained and recorded in individual plans The registered manager must ensure that all staff, including the manager, completes Adult Protection training in line with the local authority Adult Protection policy. The registered manager must ensure that all service users are protected from financial abuse and in doing so ensure that risk assessments are put in place for service users independent management of their finances and involve the service user and relevant social workers in these assessments. The registered manager must put in place a system for planning development and maintenance of the property, to include consideration for relocating the office area. The registered manager must ensure that sufficient numbers of staff are registered on NVQ level 2/3 courses, in order to meet requirements for at least 50 of support staff to attain DS0000058570.V258094.R01.S.doc 31/10/05 30/11/05 30/11/05 31/01/06 30/11/05 Tulips Care Home, The Version 5.0 Page 27 this qualification. 14 YA33 18.1(a) The registered manager must review current staffing levels to ensure that there are sufficient numbers of skilled staff available at all times to support service users assessed needs. Support hours must be agreed with each service users’ commissioning agent and the total staff establishment agreed with CSCI. The registered manager must discontinue the current arrangements for one member of staff to cover sleepovers as a live in support tenant, and must review the arrangements for the provision of night-time support, to ensure that the service users home is not used to provide accommodation for staff unless this has been agreed to be in the best interests of service users, and to ensure that adequate support is available to service users at night without having a high impact on management time. The registered provider and manager must ensure that service users are supported by two staff at all times between the hours of 8am and 10pm who are of sufficient training and experience to meet service users assessed needs. Staffing levels must be reflected in detail on the homes duty roster. Any changes to this level of staffing must not be made without prior agreement from CSCI. This was an immediate requirement and was met. The Registered Manager must produce a detailed rota showing the hours to be worked by each member of staff, including DS0000058570.V258094.R01.S.doc 31/10/05 15 YA33 18.1(a) 4.1(b) 31/10/05 16 YA33 18.1(a) 07/10/05 17 YA33 18.1(a) 31/10/05 Tulips Care Home, The Version 5.0 Page 28 18 YA33 18.1(a,b,c) 19 YA34 19.1(a,b,c) 20 YA35 18.1(a,b,c) 21 YA35 18.1(a,b,c) sleepovers, and forward a copy of this to CSCI. The home must not accept any further referrals until the management and staffing of the home has stabilised, and improved to an acceptable level in numbers and competence, and that this has been agreed with the CSCI prior to any further admissions. The registered provider and manager must operate a thorough recruitment procedure, ensuring that all staff employed are confirmed in post only following completion of satisfactory police checks, and following receipt of two satisfactory written references. The manager must ensure that the two staff currently employed who have not had CRB checks completed must not be allowed to work in the home without direct management presence and supervision, and must not engage in personal care support of any kind, or work alone one to one with service users. This was an immediate requirement and was met. The registered manager must ensure that the home has training and development plan in place, which is linked to service users assessed needs, and ensure that all staff employed have an individual training and development profile. The registered manager must ensure that all staff are inducted in accordance with a structured schedule, which meets the Sector Skills Council specifications. (LDAF or TOPPS induction) DS0000058570.V258094.R01.S.doc 31/10/05 07/10/05 31/12/05 30/11/05 Tulips Care Home, The Version 5.0 Page 29 22 23 YA37 YA37 9.2 (b, I) 38.1&2 39(a) 24 YA39 24 25 YA42 13.4 The registered manager must enrol on an NVQ level 4 course in management and care. The registered manager must ensure that appropriate management arrangements are put in place for the effective management of the home during her period of planned absence, and until she is confident that she can effectively manage the home independently. The manager must notify CSCI in writing regarding these arrangements. 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. The registered manager must ensure that safe working practices are employed in the home and that all parts the home are free from hazards to service users and staff, paying special attention to addressing the issues identified under this standard. 31/12/05 31/10/05 31/01/06 30/11/05 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 YA24 YA24 Good Practice Recommendations The homes management should give consideration make adjustments to the design of the ground floor showerroom to improve service users comfort. The registered manager should consider the introduction of a planned system or programme for maintenance and DS0000058570.V258094.R01.S.doc Version 5.0 Page 30 Tulips Care Home, The renewal to ensure the fabric and furnishings are maintained in good condition. Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Tulips Care Home, The DS0000058570.V258094.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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