CQC report explained · a nursing home
What the CQC found at Mulberry Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. They found enough staff, safe recruitment, suitable risk management, safe medicines practice and effective infection control measures.
- Effective?
- Good
- This area was not inspected during this visit. The report says the previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. The report says no concerns were identified in the information held about it.
- Responsive?
- Good
- This area was not inspected during this visit. The report says no concerns were identified in the information held about it.
- Well-led?
- Good
- Inspectors found clear management arrangements, an open culture and regular checks on quality and safety. The manager responded to complaints and incidents and involved people, relatives and staff.
What inspectors found, October 2020
Mulberry Court rated Good; inspectors found safe, well-managed care, but this was a focused inspection that did not reassess all areas.
Inspectors visited on 15 September 2020. They spoke with eight people, two relatives and seven staff. They observed care and reviewed care, medicines, recruitment, training and management records.
The inspection was prompted partly by concerns about the home. Inspectors found no evidence that people were at risk of harm. They found people were protected from abuse, received medicines safely, and had enough staff to meet their needs.
The home was described as open, well-run and person-centred. The manager and staff responded to concerns, learned from incidents and involved people, relatives and staff in improving the service.
The overall rating was Good, unchanged from the previous Good rating published in November 2018. However, inspectors only assessed Safe and Well-led at this visit. Ratings for the other areas were carried over from earlier comprehensive inspections.
Enough staff
Inspectors saw enough staff on duty and found that staff were not rushed. Staff had time to engage with people meaningfully.
“We observed enough staff on duty and deployed throughout the home to meet people's needs.” from the report
Safe medicines
People received their medicines on time and as prescribed. Staff knew what to do if an error happened, and incidents were investigated.
“Staff administered people's medicines on time and as prescribed and followed clear guidance for how people' preferred to take their medicines.” from the report
Open management
The home had clear lines of responsibility. The manager was visible and encouraged people, relatives and staff to give feedback.
“The registered manager promoted an open, inclusive and person-centred culture.” from the report
Learning from incidents
The manager investigated accidents and incidents, shared learning with staff and arranged extra support or training when needed.
“Learning from incidents was communicated effectively with staff and where necessary additional support and training was provided.” from the report
Infection control
Inspectors were assured that the home had measures to prevent and manage infection, including safe use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Inspectors raised no specific concerns in this report.
- 01What were the concerns that led to this focused inspection, and what action has the home taken since then?
- 02What are the current ratings and recent inspection findings for Effective, Caring and Responsive, which were not reassessed at this visit?
- 03How do you check that staffing levels continue to meet each person's needs?
- 04How are medicines errors or incidents recorded, investigated and used to improve practice?
- 05How can residents and relatives give feedback, and what recent changes have been made because of it?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 10 October 2020 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, November 2018
Mulberry Court is rated Good; inspectors found kind, safe care, with one choking-risk incident and some staffing and records issues addressed.
This was an unannounced comprehensive inspection on 3 October 2018, followed by a second visit on 8 October. Inspectors spoke with people using the service, relatives, staff and visiting health professionals. They also looked at care plans, medicines, recruitment, training and quality records.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found people were treated with kindness and dignity, medicines were managed safely, care plans were detailed, and people were supported with food, healthcare, activities and end of life care.
Inspectors did find some issues. On the first day, staff did not follow guidance about one person's choking risk. There had also been recent staff sickness, especially at weekends, and some inconsistencies in nutrition records and quality documentation. The manager acted during or after the inspection to address these points.
The overall Good rating stayed the same as at the previous inspection. The report says there was no evidence of serious risks or concerns from this inspection and the home's ongoing monitoring.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed people being treated with respect, kindness and dignity, and being offered choices.
“We observed staff treating people with respect and kindness during our inspection.” from the report
Safe medicines management
Medicines were stored, given and recorded safely. Staff were trained and their competence was checked.
“Medicines were appropriately managed, stored, recorded and administered.” from the report
Personalised care plans
Care plans included people's needs, preferences, communication requirements and routines. They were regularly reviewed and used to guide individual care.
“We found care plans were detailed, up to date and regularly reviewed.” from the report
Responsive activities
The home offered a weekly programme of activities and asked people what they wanted. It responded when one person asked for more activities aimed at their interests.
“A monthly meeting was held with people who used the service, to gather people's views on what activities and trips they would like to include on the programme.” from the report
Positive leadership
People, relatives and staff described the manager as approachable and supportive. The home used audits and feedback to identify improvements.
“Feedback from staff indicated there was a positive culture at the service.” from the report
Choking-risk guidance
seriousInspectors saw one staff member fail to follow the guidance in a risk assessment about choking. The manager took swift action, but you should check how this is prevented from happening again.
“On the first day of our inspection we observed a staff member failed to follow guidelines in relation to one person's choking risk.” from the report
Weekend staffing pressure
needs fixingRecent short-notice sickness, particularly at weekends, had put more pressure on staff. The home was recruiting and taking action to maintain safe staffing levels.
“some said there had been difficulties recently with staff sickness, particularly at weekends, leading to more pressure at these times.” from the report
Inconsistent nutrition records
needs fixingSome nutrition information differed between detailed care files and other records, including handover records. The manager corrected the anomalies and reminded staff about thickened fluids.
“we did note some anomalies in the information about nutritional needs held elsewhere, such as daily handover records.” from the report
Gaps in monitoring records
minorThere were gaps in the records for the 'resident of the day' checks. The deputy manager agreed to improve consistency so issues could be identified more reliably.
“We noted some gaps in the 'resident of the day' documentation.” from the report
- 01What has changed to make sure every staff member follows each person's choking-risk guidance?
- 02How do you cover weekend shifts when staff are off sick, and are there still staffing pressures?
- 03How do you make sure nutrition information is the same in care plans, handovers and other records?
- 04How are the 'resident of the day' checks now recorded and reviewed?
- 05How will you check that any actions taken after this inspection have been effective?
This was a comprehensive inspection covering all five questions and the overall quality of the service; the Good rating remained unchanged from the previous inspection. This explanation was written from the published report of 10 November 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 held its Good rating throughout.
- October 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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