CQC report explained · a residential care home
What the CQC found at Mulberry Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Three people did not receive some medicines because supplies were unavailable for between two and ten days. Equipment check records, including checks of hoisting slings, were not always complete.
- Effective?
- Requires improvement
- Several staff had overdue training, and staff did not always receive regular supervision and appraisals. Three people's Deprivation of Liberty Safeguards authorisations had expired without timely reapplications.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Inspectors saw positive interactions and found that people were involved in decisions about their care.
- Responsive?
- Good
- Staff knew people well and responded to their needs. There was a wide range of activities, including visits and opportunities to take part in the local community.
- Well-led?
- Requires improvement
- Five management changes had led to inconsistency. Audits and other checks had not found problems with medicines, legal authorisations, training, supervision or equipment.
What inspectors found, July 2019
Mulberry Court was rated Requires Improvement; inspectors found kind, responsive care but serious problems with medicines, lawful restrictions, staff support and management checks.
This was an unannounced inspection on the first day, carried out over 3, 4 and 6 June 2019. Inspectors reviewed medicines, care records, staff files and management records. They spoke with people, relatives and staff, and observed meals and activities.
People were generally treated with kindness, dignity and respect. Inspectors found good care planning, a wide range of activities and positive relationships with families. The home had adequate staffing during the inspection, and people were not rushed.
However, three people had missed medicines because supplies had run out. Three people's legal authorisations for restrictions on their liberty had expired. Some staff training and supervision were overdue, and management checks had failed to identify these problems.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. This was the same overall rating as at the previous inspection.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff treating people with dignity and involving them in their care.
“People were treated with kindness and compassion.” from the report
Activities and community links
People could take part in a wide range of activities and community visits, including outings and visits from local groups.
“There was a wide range of activities for people to engage in and to follow their hobbies.” from the report
Personalised support
Care plans included people's needs, choices and preferences. Staff knew people well and adapted communication and food support where needed.
“Assessments of people's needs were in place, and care and support were reviewed regularly and updated when required.” from the report
Medicines were missed
seriousThree people did not receive medicines because there was not enough stock. The missed medicines were for conditions including anxiety, dementia, osteoporosis and iron deficiency, creating a risk of health deterioration.
“We saw that three people had not received their medicines due to lack of stock.” from the report
Restrictions were not always lawful
seriousThree people's legal authorisations for restrictions on their liberty had expired. Applications had not been submitted in time, so people were deprived of their liberty without lawful authority.
“People being deprived of their liberty unlawfully was a breach of Regulation 13 (5) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staff training and supervision were overdue
needs fixingSeveral staff had expired training in areas including fire safety, food safety and manual handling. Staff did not always receive regular supervision or appraisal, and medicine competency checks were unclear.
“Several members of staff had not received refresher training in fire safety, food safety and manual handling.” from the report
Management checks were ineffective
seriousAudits had not identified the problems found by inspectors. There had also been five changes in management since the previous inspection, causing inconsistency.
“Audits were the responsibility of the management and due to the instability of management at the service audits had either not been completed or had failed to identify the issues we found during our inspection.” from the report
Equipment records were incomplete
needs fixingRecords did not always show that hoisting sling checks had been completed. A note said one sling was not in good order, and staff could not explain what had happened to it.
“Records of sling checks were not always completed to confirm checks of equipment had been carried out.” from the report
- 01What system is now used to make sure every person's medicines are ordered in time and never run out?
- 02How do you check that all restrictions on a person's liberty have current legal authorisation?
- 03Which staff training and medicine competency checks were overdue, and have they now been completed?
- 04How often are audits carried out now, and how do you check that they identify problems with medicines, equipment and care records?
- 05Who is currently managing the home, and how are staff supported through changes in management?
This was a planned inspection of the overall service and all five key questions, following the previous Requires Improvement rating. This explanation was written from the published report of 23 July 2019 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, March 2018
Rated Requires Improvement; inspectors found kind, personalised care, but medicines, hydration and quality checks were not reliable.
Inspectors visited without notice on 30 January and 1 February 2018. They spoke with people, relatives, staff and managers. They observed care and checked records, including care plans, medicines, recruitment and training records.
People said they felt safe. Staff were kind, respectful and knew people's routines. Care was personalised, families were involved, complaints were handled, and activities were available.
There were important problems with medicines. Several people went without prescribed medicines, some medicines were not stored safely, and homely remedies were not authorised correctly. Some people at risk of dehydration or malnutrition did not receive or have records of enough food and fluids. Audits had identified medicine problems but had not led to effective action.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also Requires Improvement. Caring and Responsive were rated Good. The report found breaches of Regulations 12 and 14, and the provider was required to say what action it would take.
Kind and respectful care
Inspectors saw staff spending time with people without rushing. People were treated with dignity and staff sought consent before entering rooms.
“We observed staff were kind and caring and were able to spend time with people.” from the report
Personalised support
Care plans included people's routines, life histories, preferences and social needs. Staff knew people well and could describe their usual routines.
“Care plans were personalised and detailed daily routines specific to each person.” from the report
Good family involvement
People and families were involved in care reviews and decisions. They could attend meetings and raise concerns through the complaints process.
“Regular reviews were held with people and their families to discuss any changes or additions to care needs.” from the report
Supportive staff training
Training, supervision and appraisals were provided. Staff said they felt supported and worked as a team.
“The training records confirmed staff received on-going training and were booked to complete any updates that were due.” from the report
Clean and accessible home
Inspectors found clean rooms and communal areas, safe hoisting equipment and clear, hazard-free corridors.
“Rooms and communal areas were in good state of décor bed linen was clean and of good quality, rooms were clean and tidy” from the report
Missed and poorly managed medicines
seriousSeveral people did not receive prescribed medicines because supplies were insufficient. Homely remedies were used without the required authorisation, and a thickener was left where other people could reach it.
“From 26 November 2017 until 29 January 2018 there had been 23 occasions where people had not received their medicines.” from the report
Not enough fluids
seriousSome people at risk of dehydration had very low fluid records over several days. Inspectors said this could cause further health problems.
“People at risk of dehydration did not receive adequate fluids.” from the report
Malnutrition monitoring
needs fixingProcedures were not always followed for people at risk of malnutrition. Food charts were missing or did not accurately show what people had eaten.
“This demonstrated that people who had been assessed at risk of malnutrition did not have their calorie intake monitored to prevent deterioration.” from the report
Repositioning records
seriousRecords showed that one person at risk of skin damage had not been recorded as repositioned on several days. Inspectors said this increased the risk of pressure damage.
“However, charts dated 25/01/2018, 24/01/2018 and 30/01/2018 showed the person had not been repositioned throughout those days.” from the report
Audits did not lead to action
needs fixingMedicine audits had identified missed medicines, but the home had not taken effective action to prevent the problem happening again.
“We did not see any actions taken to address this and prevent reoccurrences.” from the report
- 01How do you now make sure prescribed medicines are always in stock and given on time?
- 02How are homely remedies authorised and recorded now?
- 03How do you monitor fluid intake for people at risk of dehydration, and what happens when someone drinks too little?
- 04How do you check that food charts accurately record what people have eaten and that high-risk nutrition plans are followed?
- 05How are repositioning records and other risk assessments checked, and what action is taken when records are incomplete?
This was an unannounced inspection covering all five CQC questions, including the premises, care practices, records, medicines, staffing and how the home was managed. This explanation was written from the published report of 23 March 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 Mulberry Court
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- July 2019Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Registered with the Care Quality Commission on 3 December 2013.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
89 live-in carers within about an hour of Buckinghamshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,300 a week. 79 can care for a couple. 13 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.