Mulberry House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.There was an increased risk that people could be harmed. The service was in breach of legal regulations related to safeguarding, safe care and staffing. Safeguarding concerns were not always identified and reported. Accident and incident forms were not always completed. Care plans did not always contain enough information on managing risks. Medicines were not always managed safely. Environmental safety and infection prevention and control risks had not always been managed. Staff were not always well supported.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive culture of safety. Accident and incident reports had not always been completed. For example, following incidents where people had experienced emotional distress and communicated this physically to staff, staff had not always documented these appropriately. One of these incidents involved a staff member being pushed to the floor twice where they could have been significantly injured. This placed people at increased risk of harm and increased the risk of lessons not always being learnt to continually identify and embed good practice. However, relatives told us they were kept informed of incidents. A relative said, “When there have been incidents, the team manage them very well. I am always kept informed whenever there is an incident.”

The service did not always maintain safe systems of care to manage risks people could experience or be exposed to. The provider's systems were not always established or effective in areas such as ensuring safeguarding concerns always identified, risks to people and staff being well managed and care plans always being reflective of people’s needs. However, we found the service had good communication systems with people's relatives and other services they used. During our assessment, the service was supporting a person with a planned transition period to help them get used to the service. A relative told us, “I met with the manager and viewed the service, they completed a thorough assessment, and this gave me confidence that they would be able to support my [relative]. Once they agreed that they could meet their needs, we started developing the support plans”.

People were not always protected from abuse and improper treatment. The provider had failed to identify and report all safeguarding concerns to the local authority safeguarding team. Not all staff we spoke with could tell us who they could report safeguarding concerns to externally if they needed to. Failing to recognise potential safeguarding concerns and staff not always knowing how to escalate concerns externally placed people at increased risk of harm.

The service did not always plan care to meet people’s needs safely. People were at increased risk of avoidable harm as the provider had failed to fully assess known risks, such as risks relating to emotional distress, people’s mobility and health related conditions. However, there were also examples of good practice, such as a person’s care plan identifying they did not like group activities and how they would communicate if they needed support with their hygiene needs. Staff could tell us how they supported people with individual risks, such as promoting people’s safety in the community. A relative said, “Staff do know my [relative] well especially regarding how to help regulate [them] when overstimulated or frustrated.”

The service did not always detect and control potential risks in the care environment. We identified concerns with showers being able to get hot enough to scald, the safe storage of cleaning products, window restrictors not being in place on all windows and the safety of fire doors. The registered manager did not have access to all safety certificates such as those in relation to fire and electrical safety. During the assessment, the provider told us they had taken action in response to these concerns, however during our final visit we found concerns related to shower temperatures, fire doors and the storage of cleaning products remained.

The service did not always ensure there were enough staff deployed. For example, staff schedules showed female staff had lone worked with a person when the service had assessed they and the person would be at risk from this. The service used regular agency staff, but the provider had not operated a system to ensure they received regular supervision or a documented induction. Staff had not always been debriefed when they had been involved in incidents relating to people being distressed or where they had or could have been hurt. However, staff were recruited safely and received regular supervision, training and development opportunities.

The service did not always assess or manage the risk of infection. Clinical waste was not managed safely and separated from general waste. We identified concerns in relation to food storage during our first visit, the registered manager took immediate action in response to this. However, we found the overall cleanliness of communal spaces and bedrooms to be good.

The service did not always make sure that medicines administration was safe. The provider had not independently identified all staff medicines administration errors. There were increased risks medicines were not always stored safely as they were kept in an external office where initially the registered manager told us the heating would be turned off at night. This increased the risk of medicines being stored at temperatures too low. There had not been a system to confirm medicines prescriptions and instructions had been transcribed correctly on people’s records. Protocols for people prescribed ‘as required’ (PRN) medicines were not always in place. For example, a PRN protocol had not been in place for a person’s emergency epilepsy medicine. This increased the risk of people not receiving medicines safely and when they needed them. The regional manager implemented a PRN protocol for this medicine when we highlighted this concern. The registered manager investigated and acted in response to our findings about staff medicines administration errors and told us they would ensure the heating would be left on at night. There were safe systems in place to sign people’s medicines in and out when they came for their respite stays and staff knew how people preferred to receive their medicines. A relative said, “My [relative] requires support when taking medication and to ensure [relative] takes the correct dosage. As far as I am aware, staff manage this well and there have been no issues.