CQC report explained · a residential care home
What the CQC found at Tulip Gardens
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Incidents and accidents were not always investigated, analysed or used to update care plans and risk assessments. The home had enough staff, managed medicines safely overall and maintained a safe environment, but some as-required medicine instructions lacked detail.
- Effective?
- Good
- This key question was not inspected during this focused inspection, so its previous rating carried over to the overall rating calculation.
- Caring?
- Good
- This key question was not inspected during this focused inspection, so no new rating was given.
- Responsive?
- Good
- This key question was not inspected during this focused inspection, so no new rating was given.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify missing, inaccurate or misplaced information in care plans, risk guidance and medicine protocols. The home had a visible and approachable management team, and staff felt supported.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found warm, person-centred care but weaknesses in risk records, incident reviews and quality monitoring.
This was an unannounced focused inspection. Inspectors visited on 30 August 2022 and reviewed information until 22 September 2022. They spoke with people, relatives and staff, and checked medicines, care plans, risk assessments, recruitment, training and monitoring records.
The home was not always safe because incidents and accidents were not consistently investigated or reviewed. Risk assessments and care plans were not always updated after injuries or changes in need. Some medicine instructions also lacked enough detail, although staff managed medicines safely in practice and there were enough staff to meet people's needs.
The home was not always well-led. Its checks did not identify several important gaps in records and guidance. The overall rating changed from Good at the previous inspection to Requires Improvement. The report found breaches of regulations about safe care and treatment and good governance.
Enough staff
Inspectors found enough staff, including support for individual activities and visits. Regular agency staff were being used while permanent recruitment continued.
“The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Kind and respectful care
Staff showed warmth and respect, knew people well and involved them in discussions about their care.
“Staff members showed warmth and respect when interacting with people.” from the report
Incidents were not always reviewed
seriousThe home did not consistently investigate accidents and incidents, identify patterns or record how it would reduce the chance of them happening again. This created an increased risk that people could be harmed.
“There was no accident or incident analysis carried out both at a person or service level and opportunities to identify trends were lost.” from the report
Risk records were incomplete
seriousCare plans and risk assessments were not always updated after injuries or changes in need. Recommended exercises were not always included, so it was unclear whether they were being done or reviewed.
“Where people had sustained injuries following an incident, care plans and risk assessments had not always been updated to reflect this and to ensure risk mitigation was in place.” from the report
Weak quality monitoring
seriousThe home's audits and monitoring systems failed to identify several gaps, including incorrect or missing information in care files and guidance.
“Systems were not robust enough to demonstrate effective monitoring of the quality and safety of the service.” from the report
Medicine guidance needed more detail
needs fixingSome instructions for as-required medicines with variable doses did not explain clearly which dose to give and when. Inspectors said staff otherwise followed medicine systems safely.
“There was not sufficient detail to provide guidance for staff of which dose to give and in what circumstances.” from the report
Infection policy was out of date
minorThe infection prevention and control policy did not include the latest government guidance, including guidance about face masks. Inspectors found no evidence that this had affected staff practice.
“The policy did not contain the most up to date government guidance and required updating.” from the report
- 01How are you now investigating and analysing accidents and incidents, and how do you check that lessons have been acted on?
- 02How do you make sure care plans and risk assessments are updated promptly after an injury or change in need?
- 03What has been done to correct the missing information in seizure guidance and as-required medicine protocols?
- 04How do you check that audits identify inaccurate, missing or misplaced information in people's records?
- 05What action has been taken since the inspection, and what evidence can you show of improvement?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and the previous ratings were used to calculate the overall rating. This explanation was written from the published report of 18 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2018
Rated Good; inspectors found safe, kind and responsive care, with some communication and independence improvements still needed.
This was an unannounced inspection on 5 July 2018. One inspector and an expert by experience spoke with people living at the home, relatives, staff, the manager and a healthcare professional. They also observed care and reviewed care records and management documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, had their risks managed, received medicines safely and were supported by trained staff.
People were treated with kindness and respect. They were involved in decisions, supported to follow their interests and given choices about food and daily life. Complaints were handled properly and quality checks were in place.
The home had improved from Requires Improvement at the previous inspection in 2017. The earlier breach about good governance had been resolved. However, some improvements had only recently been introduced, communication tools were not always used, and independence was not supported consistently.
Safe staffing
Inspectors found enough staff to meet people's needs, following earlier concerns about staffing levels. Recruitment checks were also completed before staff started work.
“We found that changes made by the management had improved the availability of staff to keep people safe.” from the report
Kind and respectful care
Staff knew people's preferences and offered choices about care and daily activities. Inspectors saw warm, calm and dignified interactions.
“We spent time in the communal areas and saw that staff interacted with people in a warm and kind way.” from the report
Activities and personal choices
People had more opportunities to take part in activities linked to their interests, including outings, exercise and community activities.
“Improvements had been made / people had good access to activities of interest to them.” from the report
Improved management checks
The earlier problem with auditing and monitoring had been addressed. The manager and provider were carrying out checks on medicines, incidents, infection control, care plans and health and safety.
“At this inspection, we found improvements had been made across the service and the provider was no longer in breach of regulation.” from the report
Communication support
needs fixingSome staff relied mainly on their knowledge of people's gestures and sounds. Communication tools and records were not routinely available for everyone who needed them.
“The staff member said that tools to help communication were not routinely used.” from the report
Independence was not consistent
needs fixingPeople were supported to be independent in some ways, but the manager accepted that this was not consistent across the home and needed further development.
“We found that while people had some elements of their independence maintained this was not consistent throughout the home.” from the report
- 01What communication tools and records are now available for people who communicate through gestures, sounds or body language?
- 02How do you make sure each person has regular opportunities to develop and use their independence?
- 03What action was taken to ensure improvements were made promptly after the previous inspection?
- 04Who is currently responsible for managing the home, and what is the progress of the acting manager's registration application?
- 05How do you use audits and feedback from people and relatives to identify and fix new concerns?
This was an unannounced comprehensive inspection covering all five key questions, including the premises and the care provided. This explanation was written from the published report of 25 August 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Tulip Gardens
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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