CQC report explained · a residential care home
What the CQC found at Mulberry House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Requires Improvement overall, with Inadequate leadership, unsafe environmental problems and care that was not always person-centred.
Inspectors made an unannounced visit on 12 July 2023. They spoke with three people living at the home, three relatives, care staff and managers. They also reviewed records and information from other organisations.
The home supported eight people with learning disabilities and autistic people. Inspectors found safe staffing levels, safe medicines management and staff who understood safeguarding. However, risk assessments were missing for known risks, parts of the home were unclean or unsuitable, and one person did not have up-to-date care planning.
People were not always supported to follow their interests or take part in meaningful activities. Staff morale was low, communication was poor and checks by managers had not identified or dealt with important problems.
The overall rating was Requires Improvement. Safe, Effective, Caring and Responsive were all rated Requires Improvement. Well-led was rated Inadequate, meaning inspectors found widespread and significant shortfalls in leadership. The home remained in breach of regulations and received a warning notice.
Safe staffing
People, relatives and staff said staffing levels were safe. Recruitment checks had improved and the provider was no longer in breach of the staffing recruitment regulation.
“People, staff and relatives all told us they felt that staffing levels were safe within the service.” from the report
Medicines
Inspectors found that medicines were given as prescribed, stored securely and recorded accurately.
“People received their medicines as prescribed, on time and in the way they preferred them by competent staff.” from the report
Safeguarding knowledge
Staff had safeguarding training and understood how to recognise and report abuse. People and relatives told inspectors they felt safe.
“Staff understood the signs of abuse and how to report it. They were trained in safeguarding and felt confident in reporting any concerns.” from the report
Healthcare support
People received healthcare support when needed. Staff noticed changes in health and arranged timely help from health professionals.
“Staff were vigilant about any changes to people's health and wellbeing and ensured people received timely support from health professionals.” from the report
Respect and involvement
People and relatives were involved in care planning where possible. Inspectors saw respectful support for privacy, dignity and independence.
“People's views regarding their care were sought and they were empowered by staff to make decisions about their care.” from the report
Missing risk assessments
seriousKnown risks were not always assessed or recorded. This included risks linked to distressed behaviour and a damaged bathroom, increasing the risk of harm.
“These failures to effectively assess risk, and to maintain a safe and clean environment, was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Poor cleanliness and environment
seriousInspectors found stained and odorous bedding, mould and damaged walls, a soiled bin, marked surfaces and sticky floors. Action to replace faulty equipment had not been taken promptly.
“Several areas within the home were not clean. A bin outside the kitchen area was heavily soiled and the lid was open.” from the report
Activities and goals
needs fixingPeople's interests, goals and aspirations were not consistently recorded or supported. Some people were observed sitting without engagement.
“These failures to promote and document activity, aspiration, and goals with people, were a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak leadership and oversight
seriousManagement checks did not identify or resolve repeated problems. Staff described poor communication and low morale, and the provider remained in breach of good governance requirements.
“These failures to assess, monitor and mitigate risks within the service, and failure to maintain a positive culture and ensure appropriate standards were met, was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Infrequent staff supervision
needs fixingTargets for one-to-one supervision were not met. Staff said formal support from management was infrequent, limiting the home's ability to identify and deal with concerns promptly.
“This meant that management were not fully identifying any concerns within the staff team and dealing with them in a timely manner.” from the report
Food choices and quality
needs fixingFood stocks were minimal and largely consisted of cheaper value brands. Managers agreed to review the food bought after inspectors raised concerns about its quality.
“We pointed out that the impact of these actions was lower quality food for people, which was not a fair outcome for the people using the service.” from the report
- 01What risk assessments are now in place for people with known risks, including distressed behaviour and environmental hazards?
- 02What has been done to clean the home, replace damaged equipment and repair the bathroom with exposed pipe work and damaged walls?
- 03How will you record and provide activities that match each person's interests, goals and aspirations?
- 04How often will staff receive one-to-one supervision, and how will managers act on concerns raised by staff?
- 05What action has been taken in response to the CQC warning notice, and how can families see progress against the action plan?
This was an unannounced full inspection covering all five key questions and infection prevention and control; the report also compares the findings with the previous inspection in 2019. This explanation was written from the published report of 5 October 2023 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, June 2019
Rated Requires Improvement; inspectors found some progress, but care, staff support and management systems were still not reliable.
This was an unannounced inspection on 8 May 2019. One inspector observed care, spoke with relatives and staff, and reviewed care records, recruitment files, medicines, audits and safety checks. People could not describe their care directly, so observations were important.
The home had improved since earlier inspections. It now had a registered manager. The environment had been improved, infection control concerns had been addressed, meals offered more choice, and some activities and outings had started. People appeared relaxed, and relatives said they were happy.
However, all five areas were rated Requires Improvement. Inspectors found gaps in staff training and supervision, incomplete recruitment checks, poor interaction with some people, incomplete risk assessments, care that was not always personalised, and quality checks that did not identify problems. The home had been in Special Measures, but it was taken out because it was no longer rated Inadequate overall or in any key question.
The environment had improved
The provider had painted rooms, replaced windows and bought or repaired furniture. Further improvements were planned.
“At this inspection we found that improvements had been made to the environment.” from the report
Some activities had started
People had taken part in some events and outings, which relatives said was an improvement from the past.
“They [people] used to do nothing really, now they do things.” from the report
People appeared comfortable
Relatives said people were happy, and inspectors observed people looking relaxed and comfortable with staff.
“People looked relaxed and comfortable with staff.” from the report
Infection control concerns had been addressed
Problems found at the previous inspection had been corrected, and the registered manager had introduced an infection control audit.
“These had now been rectified.” from the report
Staff were not properly supported
seriousNew staff did not have a robust induction or completed training programme. Existing staff did not receive regular supervision, appraisal or competency checks. This was a legal breach.
“Good systems were not in place to support staff to be skilled and supported in their work.” from the report
Care was not always respectful
needs fixingInspectors saw staff walk away while one person was talking and saw sharp or dismissive comments. Staff needed more support and training to build positive relationships.
“On some occasions staff were not always respectful or polite towards one person.” from the report
Care was not personalised enough
seriousPeople's interests, goals and preferences were not explored in enough detail or followed through. This was a legal breach under Regulation 9.
“The management team, staff, and the provider were not fully considering if they were meeting and fulfilling people's interests, goals, and ambitions.” from the report
Quality checks missed problems
seriousThe provider's audits did not identify the shortfalls found by inspectors, and there was no effective plan to put them right. This was a legal breach under Regulation 17.
“The issues we had identified had not been identified.” from the report
Some risks were not fully assessed
needs fixingInspectors found three cases where known risks had not been properly explored in risk assessments. The registered manager said this would be addressed.
“In three cases certain risks were known about two people, but these had not been explored in their risk assessments.” from the report
- 01What checks have now been completed for all staff employment histories and references?
- 02How are you checking that new and existing staff are competent, trained and receiving regular supervision?
- 03What action has been taken to make each person's risk assessment complete and specific to their needs?
- 04How do you record and review each person's interests, goals and choices, and make sure planned activities happen?
- 05How will you show that your audits now identify problems and that the action plan is being completed?
This was a planned, unannounced inspection covering the overall service and all five key questions, including observations, records, recruitment files, medicines, audits and safety checks. This explanation was written from the published report of 27 June 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.
Every inspection of Mulberry House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 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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