Mulberry Court

On this page

• 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

We found 3 breaches of the legal regulations. Staff did not consistently protect people from abuse and improper treatment. Staff did not always identify when abuse or neglect might be occurring and had not always made referrals to the local safeguarding team in line with policy. Care plans were not always clear and did not provide sufficient guidance for staff to keep people safe. Staff were not always appropriately trained to meet the needs of people they support. Risks to people's health and safety were not always assessed or mitigated where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. People told us they did not always feel supported to understand and manage risk. People's choices and decisions were not always respected, and staff not always enable people to retain their independence. People were not always supported to have choice and control on their care. Governance systems and audits were not effective in identifying or addressing areas for improvement. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw provider's most recent satisfaction surveys completed by 4 people. All 4 answered "Yes" to a question: "I feel staff respect me?" and " I feel staff listen to me and understand me?" One person added: "Staff listen well to me and [my relative]. If staff don't listen, then [the manager] and [my relative] can see it on [electronic recording system]." Relatives commented: "I have the email contact details of the manager and deputy manager. I could ring if there was an urgent matter. Most issues get a response; a few slip through the net", "If I have any concerns I would go to the manager and I definitely would be listened to", "When I have had any queries or suggestions I have been able to immediately seek discussion with manager/deputy manager (either in person or via email). I feel that I am listened to, recently I have advocated that the sight loss is responsible for challenges, and the staff are open to discuss and give me their point of view – supply information."

We received mixed feedback form staff about the manager. Staff told us: “On a few occasions now I have gone to [the manager] regarding concerns I may have had. I rarely see any changes regarding issues raised”, “[The manager] has only been with us since September. [They] have had to learn new systems as well as try and settle into an established team. It’s not always easy and [their] approach towards staff may not always be the best. Things will hopefully settle down and maybe once [they] have settled staff morale will raise a bit.” Other comments included: “[The manager] is a fantastic manager and has helped to improve Mulberry Court in many ways” and “I have been very impressed by the way [the manager] is getting things done around both bungalows. Even a couple of people we support have said how much [they] have got done in such a short space of time.”

Accidents and incidents records were not always complete. When they were completed, they not always been reviewed following best practice guidance, risks of possible recurrence had not been assessed and staff had not discussed ways of managing similar events. We found no evidence that learning from accidents and incidents had been effectively shared with the staff team or that care plans and risk assessments had been updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support. The provider had a policy on reducing restrictive practices. However, it was not always followed. When people experienced episodes of anxiety or distress, these were not always recorded. The monitoring/analysis charts used to manage and monitor or learn from these records were not consistently completed by staff. For example, there was no evidence of oversight of completion of these charts with use of chemical restraint for 1 person. This meant that it was not possible to understand why chemical restraint was being used and if it was the least restrictive option available to staff at the time. This increases risk of unlawful use of chemical restrains, overdose and over medication with psychotropic medicines. This put people at risk of unauthorised restrictive practices.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people told us they felt safe living at Mulberry Court. One person told us: “I don't like it here, I'm not safe. There is too much change, I'm unhappy. They've told my advocate, and they are looking for an [alternative accommodation] for me and my carer.” We discussed this with the manager who assured us this person was being supported by appropriate health and social care professionals. Other comments included: “I feel safe with all the staff” and “The waking night for [person’s name] always check on you, they come and knock on the door. It's good they are there to keep me safe. They would worry if I'd go out at night.” Relatives commented: “[My loved one] receives safe care from staff at Mulberry Court and I know that is the case as [they] would definitely tell us if [they] felt otherwise” and: “I get the impression that [my loved one] likes the staff. [They] appear happy and relaxed with [staff] – indicating [my loved one] feels safe with them.” While the people we spoke to expressed that they generally felt safe with their care, our assessment found elements of care did not meet the expected standards.

Staff told us: “In the case of there being suspected abuse or mistreatment of a resident I would go immediately to the manager or team leader. In the case that I was concerned about management being the abuser I would contact the safeguarding team; I could find their number and email address on posters around the home as well as in the staff handbook”, “I would report to the manager, safeguarding, CQC or Police, whatever was appropriate” and “If I was concerned about abuse, I would report it to a more senior member of staff and outside of work I would report it to head office.”

Staff not always demonstrated good understanding around safeguarding procedures. For example, the property’s front door was left open and unattended throughout the day during our site visit despite signage stating the door must be ‘shut at all times’, chemicals were not locked away and objects which could be used to cause self-injury or inflict harm to others were accessible in bedrooms and communal areas. We raised this immediately with the manager.

Safeguarding policies and procedures were not fully embedded, and staff did not always respond quickly enough to concerns. Staff including the manager did not always recognise when abuse or neglect may be occurring and did not always follow required procedures if they do. The provider was not fully engaged with local safeguarding systems and had not always made referrals to the local safeguarding team following incidents where people had been at risk of potential abuse. This meant external scrutiny was not possible to ensure people were safeguarded from abuse. We found incidents of abuse and potential abuse had not been identified, followed up, or raised with the local authority. During the inspection we found incidents of injury and risk of avoidable harm that was not raised with the local authority and the management team were unaware of the incidents. Some of the incidents were subject to investigation by the local authority safeguarding team as they were reported by other health and social care professionals. The provider responded immediately during and after the inspection. They sought to improve the recording process within the home, arranged staff training and updated care plans and risk assessments for people living at the home.

People's choices and decisions were not always respected, and staff did not always enabled people to retain their independence. We received mixed feedback from people about how involved they were in managing risk. One person told us: “I'm unhappy here. I can't make choices; they change my schedule all the time and it's too much for me.” We discussed this with the home manager who assured us this person was being supported by appropriate health and social care professionals. Other feedback included comments; “I used to help with cooking, but staff do it now. I had an accident with the microwave so I can’t use the hob. I sort of used to help but now I can't” and “It's much better here now. I like to go swimming once a week. [Staff member] comes to watch me swimming, I can go when [staff’s name] comes.”

Staff told us: “It would be beneficial to make the individuals care plans more detailed, specifically their personal care needs and choices. Staff would be able to recognise [signs of distress] and pre-empt how to adapt to the individual needs.”

We observed people were able to move around the house and grounds freely during day one of the inspection. However, this included access to kitchen and laundry, where products were not appropriately stored as outlined in the provider’s policy or legal health and safety requirements and posed a potential risk to people. We raised this immediately with the manager.

Risks to people’s health, safety and well-being had not always been assessed or where it had, the risks had not always been managed safely and this had placed people at risk of avoidable harm. For example, people receiving blood thinning medicines were not assessed to take precautions; we found no associated risk assessments or 'flags' on their care record to indicate they were receiving blood thinners. This meant that staff may not be aware of the risks associated with this in the event of a fall or injury, and what they should be aware of to help prevent any harm. We raised this immediately with the manager. People that required support when they were anxious or distressed did not have clear guidelines in place. For example, we saw 1 person's records demonstrated they had experienced episode of severe distress and staff used unauthorised restraining technique. However, the person did not have a care plan in place to provide clear guidance for staff on known triggers, and ways to safely support the person when they were in an agitated state. Staff had not always been provided with treatment plans to reduce the risk of harm to people or where they had, had not always followed them. A visiting health and social care professional told us, "The care is generally satisfactory. That said [person] had an admission to hospital with a serious [health issue] which required surgery. [Person] has a history of [health condition] and I was disappointed that this was able to happen and become a serious issue without the staff being aware of it."

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed feedback form people and relatives regarding staffing levels. People told us there had been a high turnover of staff and management. One person told us: “The staff keep changing, there is too much change.” Relatives commented: “[My loved one] suggests by [their] comments that there is quite a high turnover of staff and a lot of bank staff. In the past there was much greater stability with long term staff” and “They have been short staffed and, as result, [my loved one’s] basic needs have been met but any ‘extra’ needs have not been forthcoming. However, we have been told that they have recruited more staff and are now fully manned.”

We received mixed feedback from staff regarding staffing levels. Staff told us: “We are only just enough for [staffing] ratios. There have been a few occasions when we were 'overstaffed', and it is so much easier for all the staff then, as it frees up one or two of us to take some residents on an outing”. Other staff commented: “[Some people] are rarely able to go out because there are not enough staff or drivers available on duty. To achieve best quality of life and meet individual’s specific needs we need more staff on a daily basis.” Staff did not always feel supported, and supervisions were not always completed for staff. One staff told us: “We have lost several good staff members in the five years I've been here. Some of those were down to poor management by previous managers."

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed people appear relaxed and at ease when supported by staff. Staff knew people's non-verbal and behaviour cues, offering reassurance and distraction techniques to defuse escalating conflict between people. There was adequate staffing to meet the needs of people using the provider. We observed people appeared relaxed and at ease when supported by staff.

Recruitment processes were not always robust. Staff were not always recruited safely. Recruitment checks were not always carried out in line with the regulations or the provider's recruitment policy. The provider failed to check proof of identity documents, references, and employment history for recently recruited members of staff. This put people at risk of receiving care and support from unsuitable staff. Supervision had not taken place as outlined in the provider's supervision policy. Staff did not always have the opportunity of one-to-one time to discuss any concerns or support needs. Staff performance relating to unsafe care was not always recognised and responded to appropriately and quickly. Staff did not always had access to training identified as necessary to meet people’s needs. There was evidence of observation and competency checks.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People had not always received their medicines in a safe way and in accordance with prescriber’s instructions which placed people at risk of harm. For example, there was no clear written instructions from a medical professional for administering 1 person’s insulin injections. Dose prescribed and recorded on their medication administration records (MAR) did not match dose being administered. Relative told us: "The staff are trained to give medication by set times of the day, I cannot disagree with that, but I am told that when my [loved one] has a broken night, [they] are not allowed to stay asleep but has to be woken to receive. Obviously it is right that the training is in place so that this medication routine is adhered to. But as [a relative] one would like there to be a better way found to suit [my loved one] sleep patterns and [their] meds timing."

The manager told us: “I am quite aware the medicines need addressing, I will look into measuring and monitoring stock like weighing the bottled medicines. Again with the [high risk medicines], I know what we have isn't enough so I will be addressing that.”

The provider had a medicines policy in place. However, it was not always followed. Medicines incidents or errors were not always reported and investigated, and monthly audits that took place did not identify areas for improvement. Medicines were not always ordered, stored, and disposed of securely. Stock checks of drugs had not always taken place as planned and were not effective. This meant there was a risk of an error. When medicines were to be given 'when required' there were not always protocols to help guide staff to when these should be administered. Records were kept when 'as required' medicines were given, the effectiveness and risks were not documented. Stock of medicines was not effectively managed and medicines were not always recorded or administered as prescribed which meant people were at risk of harm of medicines errors occurring and remaining undetected.