CQC report explained · a residential care home
What the CQC found at Mulberry Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable risk assessments, enough trained staff, safe medicines systems and good infection prevention and control.
- Effective?
- Good
- This question was not rated in this report. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- Staff were kind, compassionate and respectful. They knew people as individuals, supported their choices and promoted privacy, dignity and independence.
- Responsive?
- Good
- Care was personalised around people's preferences and communication needs. People were supported with activities, relationships, complaints and end-of-life care.
- Well-led?
- Good
- Inspectors found positive leadership, regular audits and an open culture. The management team used feedback, incidents and external advice to improve the service.
What inspectors found, August 2021
Mulberry Court was rated Good; inspectors found safe, kind and personalised care, with clear improvements since the previous inspection.
This was an unannounced inspection on 4 and 10 August 2021. Inspectors spoke with people living in the home, relatives, staff and visiting professionals. They also observed care and checked care records, medicines, staff files and management records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were all rated Good. Inspectors found enough trained staff, safe medicines support, good infection control and effective checks on risks and accidents.
People were treated kindly and with dignity. Staff knew people's preferences, supported their choices and helped them take part in activities. Care plans were personalised, and relatives were involved in reviews and decisions.
The overall rating improved from Requires Improvement at the previous comprehensive inspection in 2019. A targeted inspection in March 2021 did not change the rating. This report says the home had made steady improvements, although further work was planned.
Safe staffing and medicines
Inspectors found enough suitably trained staff and safe systems for administering and checking medicines.
“There were enough suitably trained staff to meet people's needs. People were supported safely with their medicines.” from the report
Kind and respectful care
Staff knew people well and supported them in a calm, compassionate and dignified way.
“People were supported by a kind, caring and compassionate staff team who knew them as individuals.” from the report
Personalised support
Care plans focused on people's preferences, likes and dislikes. Staff supported different ways of communicating and helped people stay involved in activities.
“People received personalised care that met their individual preferences likes and dislikes.” from the report
Learning and improvement
The management team used audits, accidents and professional advice to make changes. Inspectors found steady improvement since the manager started in the role.
“There had been steady improvements at the service since the registered manager started in their role.” from the report
Inspectors raised no specific concerns in this report.
- 01What has been maintained or changed since the Good rating in August 2021?
- 02What was the previous rating for Effective, and how does the home now assess people's health and care outcomes?
- 03What further improvements are planned for Accessible Information Standard arrangements and care planning?
- 04How would you support my relative's specific communication needs, including the use of pictures, large print or different languages?
- 05How would you involve our family in care planning reviews and keep us updated?
This was a planned inspection that rated Safe, Caring, Responsive and Well-led; the previous ratings for key questions not looked at, including Effective, were carried forward. This explanation was written from the published report of 21 August 2021 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 2021
Inspected but not rated; inspectors found safe risk management and medicines records, but concerns about staffing oversight, quality time and PPE use.
This was an unannounced targeted inspection on 10 and 17 March 2021. Inspectors looked at specific concerns about staffing, falls, pressure care, medicines, meals, wheelchair support and infection control. They spoke with staff and relatives, observed care and reviewed records.
People at risk of falls or skin damage had appropriate plans and support. Medicines records checked were complete. The home was clean and had strong arrangements to reduce COVID-19 risks, although some staff did not use PPE correctly and some areas were not well ventilated.
There appeared to be enough staff to meet people's immediate needs, but inspectors were not confident there was enough time for staff to sit, talk and connect with people. Management also needed better evidence that staffing levels were suitable in practice. The service was inspected but not rated because this inspection did not cover the full key questions.
Falls support
People at high risk of falls had risk assessments and plans. Staff understood these plans and specialist referrals had been made.
“We found they had good risk assessments and plans for staff to follow to manage this risk.” from the report
Pressure care
People at risk of skin damage had completed repositioning records and correctly set pressure-relieving mattresses. Their weight and nutrition were monitored.
“Staff completed repositioning charts in full. Staff reposition people to try and prevent people's skin from breaking down.” from the report
Medicines records
The sample of medicines administration records checked by inspectors was complete. A specialist medicines team had also found no issues in its audit.
“We checked a sample of people's medicines and saw their MARs were completed in full.” from the report
Infection control arrangements
Inspectors were assured about several COVID-19 controls, including testing, admissions, hygiene, social distancing and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Limited quality time
needs fixingStaff responded to immediate needs, but inspectors did not see enough time being spent sitting and talking with people. This may affect people's social and emotional support.
“We concluded there were enough staff to meet people's needs, we were not confident there was enough staff to chat, sit and connect with people.” from the report
Weak staffing oversight
needs fixingManagement used a tool to calculate staffing numbers but did not properly test whether those numbers worked in practice. The provider could not show the checks it had completed.
“The provider was unable to show the checks they completed to see if suitable numbers of staff were deployed.” from the report
PPE practice
needs fixingSome staff touched or wore masks incorrectly, and two staff removed PPE without washing their hands. Inspectors also found that some areas were not always well ventilated.
“We were somewhat assured staff were always using personal protective equipment (PPE) correctly and following safe IPC processes.” from the report
- 01How do you now check, with evidence, that staffing numbers meet people's physical and emotional needs on each floor?
- 02What arrangements are in place when staff are absent or when many people need two carers?
- 03How will staff make sure people receive time to sit, talk and connect, not just help with immediate needs?
- 04What checks now ensure staff wear, remove and dispose of PPE correctly and wash their hands afterwards?
- 05How do you monitor staff working very long hours and the effect this may have on care?
This was a targeted inspection of specific concerns and infection control, not a comprehensive inspection; Safe and Well-led were inspected but not rated, while the other key questions were not assessed. This explanation was written from the published report of 31 March 2021 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
5 rated inspections over 5 years: the service has held its Good rating throughout.
- August 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- August 2019Requires improvementup from InadequateSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2019Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- July 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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