Archived: Tulipa House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not consistently supported to stay safe. The provider was not doing all that was reasonably possible to reduce risk as lessons were not being learnt and applied from previous incidents. Systems in place were not effective to ensure potential abuse was recognised and reported in a timely manner. This increased the risk of potential harm. Areas of the service were not clean. Flooring was uneven in places which was a potential trip hazard. People were not consistently supported by enough competent, skilled and experienced staff to ensure people received safe, good quality care that meets their needs. There were processes in place to ensure people received their medicines safely. When people moved into the service the staff worked with other care services to support a joined-up approach. Recruitment processes were safe.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not all confident to raise concerns with the staff or management. One person said they did not trust anyone there and another person said if they had any concerns they would speak with their relative. People’s relatives said they had not had to raise any concerns recently. People had been involved in incidents and accidents which had not been robustly investigated, acted on or reported in a timely manner.

Lessons from previous incidents continued not being learnt. Some staff told us staff did not always stay in the lounge when they should do to reduce the risk of incidents occurring. For example, the risk of people falling from mobilising unsupported or sliding from their chair. We observed staff did leave people unsupported in the lounges and when they should have been supported one to one. There continued to be unwitnessed incidents in the communal areas. We raised concerns with the registered manager about staff leaving people who needed to be supported one to one, the registered manager told us that staff should not have done so and should have remained with the person to reduce the risk of an incident occurring. We saw two occasions where a person being supported one to one was left alone without staff support. Staff told us, “Staff are not being attentive, there needs to be a staff member in each lounge at all times and sometimes they are not doing that. We get told that all the time. There shouldn’t be so many falls" and “There are less falls on my shifts, because I make sure staff don’t leave the lounge and that’s why it’s happening. People are vulnerable.”

The systems and process to reduce risk from incidents and ensure incidents were appropriately managed continued to be poor and in need of significant improvement. Lessons were not effectively learnt as they were not being sufficiently applied to ensure risk was reduced. For example, one person had one to one support, they fell three times in March 2024, each time the lesson learnt was the same lesson, for staff to remain with the person at all times. In May 2024 another person being supported one to one had two falls, one of which was unwitnessed. When we visited the service, we saw a person who had one to one support being left alone twice, by two different staff. Staff were not in line of sight; this left the person at increased risk as lessons about not leaving people alone had not been effectively learnt. The analysis of incidents and accidents for overall trends across the service continued to need improving to ensure risk was being well mitigated. There was no effective overview of incidents to ensure patterns, trends and root causes were fully identified. Some incidents had not been included in the incident log, had not been analysed prior to the assessment. Incidents and accidents were analysed at individual level. However, there remained no clear analysis with conclusion for falls across the service to help drive forward improvements. For example, there was a lack of analysis to understand the root cause behind staff repeatedly leaving people alone when they were on one-to-one support. There continued to be no effective analysis of overall patterns and trends.

People and their relatives said they were able to access health care professionals, such as chiropodists, and GPs. One person said, “Staff know when I am not well. They get the doctor for me”. Another confirmed they regularly saw a chiropodist. A relative told us, “As far as I know they do have a joined-up approach, they are trying their best.” The registered manager told us, “If a new person is moving in, we ask families to be involved in getting information to go into the care plan. If a person is moving out, we support families with that too and give as much support as we can.”

The registered manager and staff worked with local authority commissioners and health care professionals to ensure people’s transition into and out of the service were effective. People were referred to health care professionals, such as speech and language therapists when required. The registered manager and staff worked with health care professionals, for example, a person was supported by the community nursing team to manage their diabetes. Staff were working with the nurses to have a small sensor fitted to the person’s arm which would continuously monitor their blood sugar levels.

The registered manager and staff worked with local authority commissioners and health care professionals to support people to transition into and out of the service.

Staff worked with other care services to support a joined-up approach. The registered manger said, “We do an assessment when someone is coming in and do care plan. On leaving Tulipa House, the new home does an assessment, we do a brief handover and send a care plan if needed. We send the medicines administration record as well and any medicines.”

People were not always protected from the risks of harm from other people living at the service. People were not consistently appropriately supported, such as people who needed one to one support being left on their own, which resulted in incidents, such as falls, taking place. Whilst people told us they felt safe living at Tulipa House, they were unable to give any reason why, other than that they knew the people living there and / or had lived there a long while. Relatives told us people had experienced falls and they had been contacted by staff when this had happened.

People continued to not always be protected from the risk of abuse, potential abuse was still not always recognised by staff. A number of concerns had not been reported as safeguarding. Some staff understood what constituted a safeguarding and how to report it. However, other staff were less clear in their understanding. Some staff had not completed training about safeguarding. Staff knew how to whistle blow but had not done so despite some staff raising concerns about the standards of care during the assessment.

People were not always been supported in a way that kept them safe. We saw there were two separate occasions where a person was left without staff support when they should not have been. On one occasion the person was left alone with someone they had had previous altercation with including ‘trying to hit each other’. The person was also left alone whilst people were making their way to the dining room. This was a known trigger for the person. There were times when staff were not present in the lounge and people were left alone.

The processes in place did not always ensure safeguarding incidents were effectively monitored, investigated and reported in a timely manner. Prior to the assessment there were multiple systems in use to record incidents. Some incidents that should have been reported as safeguarding were recorded on behaviour charts and were then not reported to the safeguarding team at the local authority prior to the inspection. This included incidents, such as, where one person had punched another person. The provider told us that incidents of behaviour where audited. However, the incidents we looked at for March 2024, April 2024 and May 2024 were not audited until June 2024. One person was involved in seven incidents which we identified should have been reported to the local authority safeguarding team in the three-month period we reviewed. The local authority safeguarding team was not informed about all incidents when they should have been so there could be independent oversight. Safeguarding incidents were not reviewed when they occurred to identify if the incident was preventable and take action to reduce risks of re-occurrence. Staff had received training in the Mental Capacity Act (MCA) and Deprivation of Liberty safeguards (DoLS). The registered manager submitted DoLS applications to the local authority when required.

Despite a lack of detailed, clear risk assessments and robust processes, people told us they felt safe with the support being provided. A relative told us staff had contacted them when their relative had fallen and need to go to hospital. When people showed signs of distress, they were not consistently supported by staff in a positive way to maximise learning for the future about the causes of their anxiety or distress. During our on-site assessment, we observed numerous times when a person, walking with purpose, was not supported in a positive way by the staff team. The registered manager did provide the person with reassurance.

Risk assessments and care plans were not consistently followed by staff. For example, people who needed to be supported on a one-to-one basis were left alone. Some staff were knowledgeable about risks to people. For example, we spoke with a member of staff about a person living with diabetes. They were able to explain the signs and symptoms they may display if their sugar level had fluctuated. However, another member of staff said, “I am not sure of the signs of someone becoming unwell [from diabetes}.” Staff recognised which people were at risk of choking and knew how to support a person should they begin to choke. Staff spoke about initially using back slaps to try and dislodge a piece of food. One member of staff said, “[Person] is at risk of choking. There should always be someone in the room.”

People were not always supported in a way that ensured they were safe. For example, one person was at risk of choking. The person needed supervision due to risk of choking. We observed they were not always supervised whilst eating.

Risk assessments and care plans were inconsistent. For example, when a person took a medicine that may place them at risk of bleeding gums, there was guidance noting a soft toothbrush should be used. Further in the care plan it was noted a regular medium toothbrush was to be used. Daily records lacked information about supporting this person with their oral care. People communicated in different ways and some people showed levels of anxiety and / or distress. Staff did not manage this in a positive way that protected their rights and dignity. 8 staff had not received training about managing challenging behaviour. Care plans did not provide staff with consistently, clear guidance to support people with their emotions. Some people’s positive behavioural support plans lacked information. For example, one person’s positive behavioural support plan noted they needed to be kept busy. There was no information to guide staff about what the person was interested in / may like to do. There was no detail for staff about how best to support the person, such as re-directing them, should they become anxious or distressed.

People were not cared for in an environment that was clean and free from odours. Relatives told us their relatives had their equipment, such as a walking frame, nearby when they visited. A relative said, “[My relative] has a wheelchair that we bought at the homes request. This is always available, and they get around the home with ease.” Another relative told us the dining room seemed safe and clean."

The registered manager had raised concerns about the flooring in their supervision meeting with the area manager in April 2024. The record noted: ‘Some windows are broken and not been fixed and chairs need replacing. lounge floor is in need of replacing due to trip hazard.’ At the time of the assessment, action had not been taken to address this. Whilst the registered manager told us they walked around the service each day, they had not identified the shortfalls we found.

There were areas of the service where the flooring had become worn, uneven and in need to repair which increased the potential risk of falls. Some areas of pathways in the garden were broken up and uneven. This increased the risk of people falling. There were risks to people from the environment which were not as well managed as they could have been. Cleaning products, which could pose a risk to people living with dementia, were left unattended in communal areas. In an audit in February 2024, it was noted ‘Flooring lifting in the lounge.’ However, the flooring was still a concern when we visited in June 2024.

Processes to monitor the safety and upkeep of the service were not effective. The maintenance and grounds audit from February 2024 noted: ‘Some issues with flooring that needs replacing in some bedrooms. Flooring lifting in the lounge. These issues have been reported. Awaiting stock to arrive.’ Action had still not been taken at the time of the assessment to address these concerns. The management team were unable to provide a copy of the most recent asbestos report for Tulipa House. Following the on-site assessment the provider arranged for an asbestos survey to be completed. The system for staff to raise concerns with the maintenance team were in place. However, the maintenance team had not always been able to remedy issues due to budgetary changes. Basic items, such as yellow and black hazard tape were not kept in stock.

People’s views on staffing levels varied. People told us, “No, they don’t come to help me. They’re all doing their own jobs” and, “I can use the call bell and they will come but I can go downstairs myself if they don’t come straight away.” Another person felt there were not enough staff at night. Some relatives told us they did not know about staffing levels as they did not go into the service other than the dining room or garden. A relative said, “There appears to be a high turnover of staff. It takes a while to answer the door” and, “Every time we visit there seems to be lots of staff – I’m not sure about staff to resident ratio but I’ve never thought it was an issue.” People’s views about their support and relatives’ views on their confidence in staff supporting their relatives varied. One person told us, “I am bored here. Some staff are good, some are not trained enough.” A relative commented, “Very confident all the staff are accommodating to [my relatives] needs.”

Staff views on staffing levels varied and some did not feel there were enough of them on duty to provide people with high quality, person-centred care. Staff told us, "We don’t always get enough time to talk to people. It depends what’s staff are on”, "Some staff stand about doing nothing", "I feel there is enough staff here" and "I don’t think there is enough staff here some days, today is a good day but sometimes there is not enough time to spend with people. It’s task, document, task, document, task document. I would rather spend time talking to people."

Staff deployment did not always ensure people were safe from the risk of potential harm. We observed one person struggling to reach an item on the floor leaning very far forward in their chair to do so. Staff in the room were engaged in an activity and did not see the person. The inspector had to intervene and ask staff to assist the person as there was a risk the person would become unbalanced and fall forward from their chair. Throughout the on-site assessment there was a lack of positive engagement between people and staff. For example, a member of staff supporting a person on a one-to-one was stood in the same room with their back to the wall and their arms folded. There were concerns about the effectiveness about some staff training. For example, one staff member was supporting a person to stand up using a three wheeled walker. They had identified that the walker was not steady but continued to attempt to support to person to use this item to stand.

There were not enough skilled, trained and knowledgeable staff deployed. Whilst there was a dependency tool, the formulas were incorrect, and the number of minutes identified for each person did not reflect the actual amount of support people needed. Staff had not completed training relevant to their roles, such as positive behavioural support (PBS). The lack of PBS training was evident in our observations. The service had a dedicated trainer who worked with staff two days a week. The registered manager did not have clear oversight of staff training. There were large gaps in staff training and several training topics which were marked ‘no rec’. We checked this with the registered manager who confirmed this meant there was no record of this being completed. The registered manager had not considered the need for kitchen and maintenance staff, to complete mandatory training, such as safeguarding and supporting people living with learning disabilities and autism. Staff were recruited safely. The provider sought references and completed Disclosure and Barring Service. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff met with their line manager for one-to-one supervision.

People were not supported in a clean environment, free from the risks of infection. People’s rooms and furniture were unclean and worn and there was a potential risk of infection. Relatives told us, and staff confirmed, they met their relatives in the dining room, or occasionally in the garden. Relatives gave mixed feedback, including “There could be improvements, sometimes I do feel [my relative] is left in their pads for longer than they should be. But this is due to the pressures”, “I have raised some concerns about the general cleanliness of the service. It has since improved” and, “It seems clean. I wouldn’t know about the rest of the home, or [my relative’s] room.”

The registered manager told us they walked round the service to check the cleanliness of bedrooms, laundry and kitchen. They said, “I go round and check personal protective equipment (PPE). I make sure staff are wearing PPE and wiping down surfaces.” The registered manager told us the kitchen was due for renovation in September 2024 and they had asked staff to deep clean the kitchen.

Areas of the service were not kept clean and hygienic. Skirting boards and walls in some communal areas were ingrained with dirt and stains. People’s rooms were not always clean. For example, one person’s room had ingrained dirt on the ledges around the hand basin and a chair with dirty, worn arms. On the second day of the on-site assessment additional staff were completing a deep clean of some areas of the service. Bathrooms had paper towel dispensers and soap dispensers which were stocked. Pedal bins were lined. Clinical waste bins were lined with yellow clinical waste bags.

Checks and audits of the cleanliness of the service were not effective. Checks had identified some shortfalls, such as chairs needing replacing, however action had not been taken to remedy this. The checks and audits had not identified that areas of the service were dirty. The nominated individual completed monthly checks at Tulipa House. These had also not identified the concerns we raised during the assessment. The nominated individual arranged for deep cleaning of some areas of the service to start during the second day of our assessment. The service had a redecoration schedule in place and the entrance to the service had been painted.

People received their medicines on time and as prescribed. In a recent survey people and their relatives had fed back that they received good support with their medicines.

Staff told us that medicine administration had improved. There was now an electronic medicine system in place which supported staff to administer people’s medicines safely. Staff told us they were not interrupted during medicine rounds as they wore a tabard during administration, we observed this was the case.

Medicines were now well managed. The provider had introduced and electronic medicine administration records (MAR) system. MARs were now completed as required. Where people had medicine which was administered via a transdermal patch these were rotated appropriately to reduce the risk of skin irritation. As and when medicines (PRNs) were administered appropriately. These were medicines which are administered when required, such as pain relief. There was guidance for staff including when to offer people these medicines, how often these medicines could be taken and how much could be taken within a 24-hour period. The support people needed with their medicines had been assessed. There was guidance for staff on how to identify if people were in pain when people did not always express this verbally. Medicines were stored appropriately and disposed of in a safe way when no longer needed.