CQC report explained · a residential care home
What the CQC found at Mulberry House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that people were safe, with better safeguarding, risk management, staffing, infection control and medicines arrangements. They said the new processes and training still needed to become fully established so that safety remained consistent.
- Effective?
- Good
- Staff had relevant training, competency checks, supervision and induction. Care plans were detailed and up to date, and people received support with nutrition, hydration and healthcare.
- Caring?
- Good
- Staff were calm, kind and respectful. People were supported with their choices, privacy, independence and personal preferences, and families said communication had improved.
- Responsive?
- Good
- Care was personalised and adapted when people's needs changed. People had access to activities, family contact and support for their interests, with complaints handled more effectively.
- Well-led?
- Requires improvement
- Leadership, staffing stability and governance had improved, but the arrangements were still new. Inspectors said the systems needed more time to become established and to reduce the risk of earlier problems returning.
What inspectors found, July 2022
Rated Requires Improvement; care had improved greatly and was no longer in special measures, but safety systems and leadership still needed to become consistent.
This was an unannounced inspection on 14 and 17 June 2022. Inspectors spoke with people, relatives, staff and visiting professionals. They reviewed care plans, medicines records, staff files and management records.
The home had made substantial progress since its previous Inadequate rating. Care plans, risk assessments, medicines systems, staffing, infection control and staff training had improved. People and relatives described kind care, better communication and more activities.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement because new systems and the management arrangements had not yet been fully embedded. The home was no longer in special measures.
Kind and respectful staff
Inspectors saw positive relationships between staff and people. Staff supported privacy, dignity, independence and individual preferences.
“Staff were calm, kind and respectful of people.” from the report
Improved care planning
Care plans had been rewritten and reviewed. They gave staff detailed information about people's health, history, needs and preferences.
“Comprehensive electronic care plans contained information about peoples' lives and medical history, healthcare conditions, their care needs and the outcomes they wished to achieve” from the report
Improved staffing and training
The staff team was more stable, with enough staff to meet people's assessed needs. Training, competency checks, supervision and induction had improved.
“The staff team was no longer relying on agency staffing so there was a more permanent team.” from the report
Better food and hydration support
Staff understood people's dietary needs and preferences. Weight and hydration were monitored, with extra support and suitable drinks available where needed.
“There were now hydration hostesses who monitored people's hydration needs each shift.” from the report
Systems not yet fully established
needs fixingThe new safety and governance systems had not been in place long enough to show that they would remain effective. The home still had support from the local authority and quality assurance team, although this was reducing.
“Although the quality assurance governance systems were new and had not yet had time to fully embed to show sustainability” from the report
Leadership was still changing
needs fixingThere was no registered manager in post during the inspection. A new permanent manager was due to start in August 2022, while interim and peripatetic managers were overseeing the home.
“At the time of our inspection there was no registered manager in post.” from the report
Previous serious problems needed to stay resolved
needs fixingThe report says earlier problems had been addressed, but continued embedding was needed to reduce the risk of them happening again. This applied across safety, care and governance.
“Systems needed to continue to be embedded to ensure consistent leadership and to mitigate the risk of the issues we found at the last inspection happening again” from the report
- 01Who is now the registered manager, and how has the management team changed since the inspection?
- 02How do you check that the new safeguarding, risk and medicines systems are being followed consistently?
- 03What evidence shows that improvements have continued since the home left special measures?
- 04How do you review staffing levels when people's dependency or support needs change?
- 05How are families involved in care plan reviews, complaints and decisions about activities?
This was an unannounced planned reinspection of the previous rating, covering all five key questions and infection prevention and control, with checks on whether legal requirements had been met. This explanation was written from the published report of 23 July 2022 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, February 2022
Rated Inadequate and placed in special measures; inspectors found people at serious risk because care, staffing and management systems were not safe or effective.
Inspectors visited on 14 and 16 December 2021. The first visit was unannounced and the second was announced. They spoke with people, relatives and staff, and checked care plans, medicines records, staff files, incident records and management audits.
They found widespread problems with risk management. These included falls, choking, poor moving and handling, pressure damage, dehydration, malnutrition, continence care, infection control and medicines. Some people could not use working call bells, and there were no reliable systems to check on people who could not use them.
Staffing and leadership were also poor. Care plans were out of date, agency staff often did not know people's needs, training and supervision were incomplete, and important incidents were not always recorded or followed up. People and relatives said communication was poor, although they generally said staff were kind when they provided support.
The overall rating was Inadequate. Safe, Effective and Well-led were each rated Inadequate. The inspection was focused on those three areas, so the other two ratings were not reassessed in this report. The home was placed in special measures.
Kindness when support was given
People and relatives generally said staff were kind and caring when they provided support.
“However, people and relatives generally said that when people were supported staff were kind and caring.” from the report
Spacious surroundings
The home was spacious, with adapted facilities, a lift, communal rooms and large grounds.
“The premises are large and spacious enabling people move around the home easily with access to a central lift.” from the report
Some COVID-19 controls
Inspectors were assured about several COVID-19 arrangements, including PPE, visiting, testing and the infection control policy.
“We were assured that the provider was using PPE effectively and safely.” from the report
Secure medicine storage
Medicines were stored securely and storage temperatures were monitored.
“Medicines were stored securely, and temperatures were monitored to make sure they were stored correctly.” from the report
People were at risk of harm
seriousRisk assessments and care plans did not reliably explain how staff should keep people safe. Inspectors found unsafe support with falls, choking, pressure care, call bells and moving equipment.
“The lack of risk assessments and safety monitoring systems in place, put people at risk of harm.” from the report
Food, drink and medicines
seriousPeople did not always receive suitable diets or enough support with eating and drinking. Medicines were missed or given late, and records did not always show whether medicines had been given.
“People did not always receive their medicines as they were prescribed which put them at risk of ill health.” from the report
Infection control
seriousShared equipment was not always cleaned, waste and soiled laundry were not managed properly, and some staff lacked infection control training.
“The lack of robust infection control and prevention practice put people at risk of cross infection.” from the report
Staffing and training
seriousThere was a high use of agency staff, poor deployment and incomplete induction, training, supervision and competency checks. Agency staff did not always have the information needed to support people safely.
“The failure to ensure the effective deployment of suitably competent and experienced staff is a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak leadership and oversight
seriousThe home did not learn effectively from earlier inspections or incidents. Audits, care records and improvement plans did not identify or resolve serious problems.
“There was a failure to act upon feedback from previous inspections to become compliant with the regulations.” from the report
Consent and safeguarding
seriousMental capacity and Deprivation of Liberty Safeguards records were incomplete. Safeguarding incidents were not always recognised, reported or followed up.
“Poor safeguarding systems, processes and practices at the service, put people were placed at risk of harm.” from the report
- 01What urgent changes have been made to risk assessments and care plans for falls, choking, pressure care, continence and moving and handling?
- 02How are agency staff now given current information about each person's needs, risks, diet and preferences before starting a shift?
- 03How do you check that medicines, including creams and other topical preparations, are given on time and recorded correctly?
- 04What systems are now used to monitor food and fluid intake, and how are people at risk of malnutrition, dehydration or choking supported?
- 05Who is currently leading the home, and how do they check that incidents, safeguarding concerns, training and care quality are acted on?
This was a focused inspection of Safe, Effective and Well-led, with infection prevention and control also reviewed; Caring and Responsive were not reassessed in this report and previous comprehensive inspection ratings were used in calculating the overall rating. This explanation was written from the published report of 5 February 2022 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Mulberry House
4 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022InadequateSafe: InadequateEffective: InadequateWell-led: Inadequate
- February 2021Inspected but not ratedSafe: Inspected but not rated
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018
Registered with the Care Quality Commission on 20 July 2018.
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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17 live-in carers within about an hour of Devon
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 £1,270 a week. 15 can care for a couple. 13 years' experience on average.
“She is such a warm and gentle person while being professional and competent at the same time.”
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
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.