Mulberry House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance. The provider had not always ensured their systems were effective or ensured oversight of quality, safety and management of risks.

This service scored 50 (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 clear shared vision, strategy and culture based on transparency, equity and equality. Safeguarding concerns were not always identified and reported; we identified concerns with reporting of incidents and accidents and debriefing and supporting staff. These increased risks relating to the service not always having a positive listening culture that promotes the right care, the right support and the right culture. However, all staff and leaders we spoke with where passionate about promoting people’s independence and providing opportunities for new experiences and positive outcomes.

The service did not demonstrate they had capable leadership with the right skills and knowledge as we identified breaches of the legal regulations and concerns in areas such as safeguarding, safe care, person-centred care, staff support and governance. Leaders had not independently identified and taken action in relation to these concerns prior to our assessment. Although, staff felt they could approach leaders with concerns and they would be addressed, leaders were not always proactive in identifying poor cultures that affected the quality of people’s care and could have a detrimental impact on staff.

Due to our findings that accidents and incidents were not always reported by staff or identified by the provider, we could not be assured people and their relatives would be informed of these promptly and would be given an apology where required. However, people and relatives did not raise any concerns to indicate they could not speak up or their voices would not be heard. A relative said, "I feel very informed on all aspects of [Person's] care and am very happy to communicate my concerns or questions to staff members in charge."

The service valued diversity in their workforce. Staff and leaders did not raise any concerns about how the serviced worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service did not have good governance systems in place. They did not act on the best information available to them about risk, performance and outcomes. The provider had not identified concerns related to, safeguarding, managing risks, medicines, staffing levels and support, infection prevention and control, safety of the environment and care planning. The provider responded to our concerns which included reviewing these areas, making improvement and planned further actions they would take. We will check for sustained improvement at our next assessment.

The service understood their duty to collaborate and work in partnership with people and their relatives. A relative told us, “When we were going through a difficult time with my loved one transitioning from children’s services to adult, Mulbury House helped us and were very flexible with the times my loved one was supported.”

The service did not always focus on continuous learning and improvement. Where accident and incident forms had been documented, there were no systems to analyse these for themes and trends or systems in place for the registered manager to confirm appropriate action had been taken. Systems to review care plans were not effective as the service had not identified errors and inconsistencies we highlighted during our assessment. However, staff did receive time and support to develop their skills. At the time of our assessment the registered manager was completing a relevant industry recognised diploma and staff confirmed they had access to training that supported them in their roles.