Archived: Tulipa House

Ratings

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

This assessment took place on 5 June 2024 and 11 June 2024. We looked at 18 quality statements in the key questions of safe, caring and well-led. The rating remains Requires Improvement. Risks to people’s health, safety and well-being were not consistently managed. Incidents and accidents were not effectively monitored and managed. There were not always enough staff to provide people with the care and support they needed, when they needed it. Areas of the service were not well maintained and were not clean. Whilst we saw some positive interactions between staff and people, people were not always spoken with or about in a kind way. People were not always offered choices, such as what to wear each day. There was a lack of oversight of staff practice and poor communication. The registered manager and staff did not demonstrate a learning culture which focused on listening, learning and driving improvements. Systems and processes to monitor the quality and safety of the service were not effectively managed. People were supported to have their medicines safely. People were supported by staff who had been safely recruited. There were processes to ensure there was a joined-up approach with health care professionals when people were moving into or out of the service. People were referred to health care professionals when needed. During this assessment we found the provider had failed to make the improvements needed to ensure people received safe, good quality care. We identified 5 breaches of regulation in relation to safe care and treatment, governance, staffing, the premises and dignity and respect. This meant people using the service were at risk of harm.

People's experience of this service

We observed people’s experience of care and support during our on-site visits. We spoke with relatives to gain their views of the support their relatives received. At our assessment we found care did not meet the expected standards. We used the Short Observational Framework for inspections (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We observed some staff not engaging with people and others who took time to chat with people when they were able to. People were not consistently supported to stay safe or to have choice and control over their day to day lives. People were supported by staff who had been recruited safely. People were supported to see health care professionals when needed, and their medicines were managed safely.