Mulberry Court

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

We found 3 continuing breaches of legal regulations in relation to safe care and treatment , safeguarding, consent to care and treatment and governance. Safeguarding policies and procedures were not fully embedded and staff had not always responded quickly enough to concerns. The service had not always fully engaged with local safeguarding systems. Staff including manager had not always recognised when abuse or neglect may be occurring and had not always responded quickly enough to concerns. Risks to people’s health, safety and well-being had not always been assessed or when it had, the risks had not always been managed safely placing people at risk of avoidable harm. The provider’s approach to anticipating and managing risks to people was reactive rather than proactive and had not been fully embedded or recognised as being the responsibility of all staff. Care plans were not always clear and did not provide sufficient guidance for staff to keep people safe at times of emotional distress. Staff were working with limited guidance to understand peoples’ emotional responses and behaviours. The culture of safety and learning from events that had either put people and staff at risk of harm, or that had caused them harm was not fully embedded. Safety of medicines administration and storage had been vastly improved with the development of a separate medicine’s storage room, complete with air conditioning to ensure a constant temperature. However, we found the provider’s medicine management policy had not always been followed, and there were still areas of medicines processes that needed to be improved. People expressed that they were happy with staff supporting them and staff knew them very well. Turnover of staff including management remained high, which impacted on care delivery. Staff thought they had sufficient training to meet people’s needs and felt there were recent improvements in supervisions and support they received from the management team.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The culture of safety and learning from events that had either put people and staff at risk of harm, or that had caused them harm was not fully embedded. Safety events were not always investigated and reported on thoroughly, which meant lessons were not learned to continually identify and embed good practices. Staff had not always recognised concerns, incidents or near misses. For example, when people experienced episodes of anxiety or distress, these were not always recorded or were recorded incorrectly and inconsistently. Furthermore, the monitoring / analysis records used to manage and monitor or learn from these incidents were not effectively reviewed or scrutinised by the management team. This meant it was not possible to identify trends and patterns in these incidents, recognise potential triggers or understand the purpose / functions of behaviours. Opportunities to learn from these incidents and prevent future re occurrences were missed. Staff worked with limited information on how to identify when and how they should intervene to prevent or reduce the likelihood of an episode of emotional distress. This increased the risk of people repeatedly experiencing similar incidents in future which had a detrimental effect on people’s mental health and well-being and maintaining positive relationship with their peers. This was a repeated breach and continuous failure to establish comprehensive risk mitigation plans for people which placed them at risk of harm . People told us they were frustrated when incidents between them and their peers repeatedly occurred: “It’s [very] annoying here. [The manager] needs to deal with it, it’s not pleasant sometimes. Sooner they sort [them] out, the better. [My relatives] will be shocked, it's an awful mess here. They won't be happy when they see what's happening” and “I need to speak about it to the manager, I'd like to speak to the manager. It's bad news and I'm very angry about the naughty thing that happened here.”

We received mixed feedback from staff about the culture of openness and transparency at Mulberry Court in which all safety concerns raised were valued as integral to learning and improvement. Staff told us the culture had improved over last 2 months with the new management in place. We were not able to review sustainability of these improvements. Staff expressed: “I have enough training to support people's complex needs. I have one to one supervision with senior member but not regularly”, “Things much improved from previous manager, they are putting things in place to raise the standards in the service and supporting the staff to meet these standards. There is no longer a blame culture, rather one that looks for you to learn and improve”, “I feel supported and my views I put forward to help Mulberry Court and the people we support are actually taken into account. We now get regular meetings to air our opinions which we didn't before. I feel heard now that [manager’s name] is here and feel like we can actually make progress and work as a team!” and “On my arrival and for the first few weeks there was a low atmosphere and I quickly discovered this was down to how staff had been treated with little respect by the previous manager, this has dramatically improved, and I have even been told by staff that everyone is a lot happier and more relaxed now.”

Safety concerns were not consistently identified or addressed quickly enough. Necessary improvements were not always made when things went wrong. Learning lessons from events and actions taken to mitigate risks was not applied widely to support improvement in other areas where relevant, as well as practices that were directly affected. Accidents and incidents records were not always completed or were not completed correctly and consistently by staff. When they were completed, they had not always been reviewed by management following best practice guidance. Staff had not always had an opportunity to discuss ways of managing similar events and the risks of possible recurrences had not been effectively assessed and mitigated. The provider had processes in place to ensure learning from accidents and incidents was shared widely with the staff team, but this was not always effective. There was some evidence of care plans and risk assessments being updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support. However, this was not applied consistently.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people told us they felt safe living at Mulberry Court. Comments included: “I feel safe. There are all these new [staff] that work waking nights and there's [staff name] on days, they are quite good” and “I am safe, they shut the main door and keep things locked. Staff are always kind and willing to help.” Relatives agreed: “There has been a difficult period of uncertainty and change at Mulberry Court in the past 6 months, things took a downturn, which led me to try to find another care home. But then I felt reassured to give [the provider] time to resolve after previous manager left and [manager’s name] took on interim management, while [the provider] sourced permanent replacement”, “[My loved one] does feel safe at Mulberry Court, there have been problems in the past between [my loved one] and particularly one of the other residents but measures have been put in place to give them skills to cope when incidents occur”, “[My loved one] has generally received safe care” and “[My loved one] is incredibly happy at Mulberry Court and often does not want to come out to us as [they] are well settled there and it is definitely [their] ‘home’.” While the people we spoke to expressed that they generally felt safe with their care as described by people, our assessment found elements of care did not meet the expected standards.

The provider had safeguarding policies and procedures in place, but they were not fully understood or consistently followed by staff. Staff told us: “Any concerns of abuse within the service depending on who is involved will be reported to [manager’s names]. If there is a concern regarding the service it will be reported via whistleblowing, there are posters around the service to show how to appropriately contact the whistleblowing services”, “I would, without delay, report this to my manager. If I felt it was the manager who was the abuser, I would report this to the police and safeguarding” and “I would initially inform my line manager unless they were the abuser. Otherwise head office or local authorities.” Staff expressed they had awareness and understanding of abuse or neglect and knew what to do to make sure that people’s human rights are not breached or violated.

We observed staff lacked understanding of safeguarding and how to take appropriate action. Staff had not always recognised when abuse or neglect was occurring and had not always followed required procedures to keep people safe and to reduce the risk of avoidable harm. For example, we observed the property’s front door was left open and unattended during our site visit despite signage stating the door must be ‘kept shut at all times for security reasons’. On arrival, staff did not respond promptly to attend the front door, despite inspectors repeatedly pressing the doorbells and attempting to get staff attention through the windows from the carpark. We observed chemicals and medicines were not locked away as per providers policies and procedures and were accessible to people living at Mulberry Court. This was a repeated breach of regulation. We raised this immediately with the manager and they took appropriate action to address this.

Safeguarding had not been given sufficient priority and people had experienced, or were at significant risk of bullying, harassment, avoidable harm, abuse or neglect. Staff were up to date with safeguarding training. However, staff had not always demonstrated understanding of good safeguarding practice guidance and had not always recognised or responded appropriately to abuse and neglect. People were not actively supported to understand their human rights, what constitutes safeguarding and how to raise safeguarding concerns. The provider was not fully engaged with local safeguarding systems and had not always made referrals to the local safeguarding team following incidents where people had been at risk of abuse. This meant external scrutiny was not possible to ensure people were safeguarded from abuse. During the inspection we found incidents of harm which were not identified, followed up or raised with the local authority and the management team were unaware of the incidents. This was a repeated breach of regulation. The provider responded promptly to address shortfall identified during and after the inspection. They sent us evidence to say they sought to improve the recording process within the home, engaged with local authority to arrange additional staff training and intended to update care plans and risk assessments for people living at the home. We were not able to review actions taken or how sustainable these improvements were.

We received mixed feedback from people about how involved they were in managing risk. When people communicated their needs, emotions or distress, people felt staff did not always manage this in a proactive and positive way that protected people’s rights and dignity. Opportunities to maximise learning for the future about the cause of peoples distress were missed. People told us: “I like being here by myself but sometimes I don't like the atmosphere of the shouting and getting cross. People get cross with each other in general. We all try our best. [Manager’s name] needs to start making sure people are happy living here” and “It's very good, I can go fishing when I want, there's enough around here to do.” Relatives commented: “We do feel there ought to be some measures put in place to encourage mental well-being like ‘conversation’ about everyday events - like what is in the news, football results etc. We believe they need more things devised during the day to give something stimulating to do. We have talked to [manager’s names] about this who say they are going to address this” and “[Our loved one] gives the impression of understanding everything that is said, but a simple check shows that this is not the case. There have been one or two occasions when [our loved one] has misunderstood a message and reacted badly.” Staff were working with limited guidance to understand peoples’ emotional responses and behaviours, and recognise and avoid potential triggers, focusing on proactive rather than reactive strategies intended to make sure that service users had what they needed and wanted on a day-to-day basis and also included ways to teach service users appropriate communication and life skills.

Staff told us they actively supported people to make choices, so they had as much control and independence as possible. Comments included: “Where possible individuals are given a choice that is best suited to them, often between 2 items shown in front of them. On a further level where appropriate individuals are spoken to about their support plans to enable them to have a say and make any changes, they feel appropriate”, “We read and know [people’s] support plans, ask them and listen to them, they may like input from family on this. They have a choice, information is given and explained and again they are listened to” and “I ensure that people’s needs and wishes are taken into account by regularly consulting their care plans and engaging with them directly to understand their preferences. I always take the time to ask individuals about their choices, such as what they would like to wear, eat etc.” Staff had limited information to identify when they need to intervene to prevent or reduce the likelihood of an episode of distress and had not been supported to mitigate risks to people leaving them at risk of harm. When positive behaviour support plans were in place, they were not always followed by staff. For example, we reviewed the most recent incident when 1 person purchased of 19 tonnes of soil which was delivered and unloaded on the car park in front of bungalow 2. Other people using the service had not been consulted. This person’s care plan offered limited guidance and strategies for staff on how to support them with maintaining positive relationships with others. Staff were told about the delivery and the chosen place to unload soil in the morning. There was no record of any preventative measures used, involvement or coordination of the soil delivery by staff or discussions held with any of the other service users. This led directly to 3 further safeguarding incidents causing psychological distress to people.

We observed people were able to move around the house and grounds freely during our on-site inspection. This included access to the medicines room and chemicals storage room, where substances hazardous to health were not stored appropriately as outlined in the provider’s policy or legal health and safety requirements. We raised this immediately with the manager and they addressed these issues. We observed people getting increasingly agitated and distressed due to the incident of 19 tons of soil being unloaded in the carpark the day before. We witnessed an incident of physical and verbal aggression between 2 people. Staff intervened and successfully used distraction techniques to deescalate situation. We were made aware of another 2 incidents which happened the day before caused directly by the soil delivery. We reviewed 1 person’s care plan and daily records and found their care plan did not offer any guidance for staff on how to support them should they become distressed and display aggressive behaviour towards others. Management told us this person did not usually display this type of behaviour. We reviewed their daily records and noted a trend across 3 separate incidents in last 2 months leading to this incident. The lack of recognition of repeated pattern of behaviour and failure to have a comprehensive management plan around this placed people at risk of harm.

Risks to people’s health, safety and well-being had not always been assessed or where it had, the risks had not always been managed safely and this had placed people at risk of avoidable harm. The provider’s approach to anticipating and managing risks to people who used the service was reactive rather than proactive and had not been fully embedded or recognised as being the responsibility of all staff. People who required support when they were anxious or distressed did not have clear, comprehensive and prevention focused care plans in place. Staff did not fully understand the systems and strategies and had not used them consistently, which meant reporting incidents, risks, issues and concerns was unreliable and inconsistent. For example, we reviewed care plans and daily records of 2 people who had been identified as at risk of skin integrity breakdown who needed support to be regularly re-positioned by staff. We found staff were not following the support plans in place, exposing people to an increased risk of harm. This was a repeated breach of regulation. Information about risks and safety was not always comprehensive or up to date. Safety concerns were not consistently identified or addressed promptly. For example, staff had not been provided with support plans to reduce the risk of harm when people become distressed and where they had, staff had not always followed the plans. We looked at the care plans and daily records of 3 people involved in recent safeguarding incidents. We found that people involved did not always receive appropriate care and treatment and appropriate risk assessments were not in place for each individual. Staff were working with minimal guidance to understand people’s emotional and behavioural needs, to recognise and avoid potential triggers.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People expressed that they were happy with staff supporting them. One person told us: “The staff are good; they are quick off the mark.” We received mixed feedback form people and relatives regarding staffing levels. Most people felt there were sufficient staff deployed. Relatives understood there were problems in recruiting staff to this, and most care services. Relatives commented: “Staffing levels remain insufficient to keep all the residents gainfully occupied. E.g. cooking support for other residents essentially means a member of staff doing it for them in haste, rather than doing it with them and building healthy skills", “During the previous recruitment effort [manager’s name] told me that they were having to take staff from abroad and several who could not drive simply to keep staff numbers up. However, I assume such limitations are endemic to care homes due to low rates of pay. [The manager] told me that another recruitment drive was underway to reduce reliance on agency staff who require regular staff to be on site” and “There wasn’t enough staff before the CQC inspection in March, but we believe that has been resolved. We did complain that sometimes when we rang, we could not get through but recently we the phone has always been answered.” People and their relatives expressed concerns about a high turnover of staff and management. Relatives told us: “We've been concerned about the many different managers and the changes, but the carers are very good. I've not seen neglect or any problems from the care staff” and “It has been hugely dismaying to find that successive managers were appointed who were out of their depth with regard to compliance issues and short of resources to run the service effectively. We really hope that [manager’s name] will receive the support and resources to raise standards.”

We received mixed feedback from staff regarding staffing levels. Comments included: “Lately there have been a lot of agency staff covering weekends. I feel that people’s basic needs are covered but we could do better, especially around activities. There are very few drivers to take people out and very little time for any one-to-one activities”, “Sometimes it feels as though there aren't enough staff. Maybe because we use a lot of agency staff during the day rather than regular staff. The agency staff returning regularly are brilliant though, but they are not medication trained or can support [people] by taking them out in their cars”, “On days where there are agency staff, especially agency staff who haven’t been to the service before, there is more of a struggle to assist [people] to go out in the community. Another member of staff throughout the day as well as an increase in our own staff would allow individuals to receive their allocated one to one time in, or out of the service” and “A decrease in agency would lead to an improvement within the service though I am aware there is recruitment being done on a regular basis as well as a few individuals starting once they have had their recruitment cleared.” Staff thought they had sufficient training to meet people’s needs. Staff told us: “I feel like I have had a lot of training about complex needs. With our previous manager we didn't have regular supervisions but now we are playing catch up and everyone is currently up to date with regular supervisions”, “Personally I would prefer more face-to face training rather than online. Supervisions much improved in the past few months, not just how often but the quality of it and now getting feedback. If I have an issue, I do not have to wait for supervision I can see manager anytime” and “I feel that the training I have received is very comprehensive, it enabled me to fully support all clients. Regular supervisions are helpful to check my progress and voice any concerns."

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed people appear relaxed and at ease when supported by staff. We noted lots of laughter and chats about planned activity and encouragement to eat breakfast. At the time of our on-site visit there was adequate staffing to meet the needs of people using the provider. Staff knew people's non-verbal and behaviour cues, offering reassurance and distraction techniques to defuse escalating conflict between people.

The provider had arrangements in place to ensure there were always enough competent staff on duty to support people to stay safe. When required, agency staff were deployed to cover vacancies and absences. We were not assured staff always had the right mix of skills to meet all people’s needs. Turnover of staff remained high, which impacted on care delivery and meant people’s care and support had not always been safe and consistent. The provider had recognised the impact of this and was working with the staffing team to make improvements. Recruitment was underway for a number of positions and multiple new staff recently commenced employment in various roles including a new manager. The provider told us workforce pressures had always been an issue at Mulberry Court due to the overall demographic and geographical location of the service. However, a recent increase in applications for support worker positions had been noted, and there were several staff midway through the ‘onboarding’ process via safer recruitment. The provider aimed to become agency free by the end of 2024 with all vacant positions filled with permanent and trained staff. The manager told us: “This will have a positive impact on the service for both the individuals we support and the existing staff team and will strengthen all aspects of the care and support we deliver, offering improved consistency and continuity, enabling us to focus on longer term service developments for Mulberry Court.” Staff told us supervision and support from management improved over the last 2 months with the most recent change in management. Supervisions had taken place, and staff had the opportunity of one-to-one time to discuss any concerns or support needs. We will review the sustainability of recent improvements at the next inspection. Staff had access to training identified as necessary to meet people’s needs. There was evidence of observation and competency checks.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt they received their medicines in a safe way. One person told us: “I get my medicines; I couldn't say what because I have quite a lot and my memory is not so good these days.” Relatives commented: “[My loved one] is well supported. [They] are good at taking medication but must be observed. We have no concerns about this”, “Staff know [my loved one] well and want what’s best for [them]. Like [they] got antipsychotic meds prescribed but we know staff don't use medicine to make [my loved one] like a zombie and calm [them] down. One of staff told us [my loved one] has a sparkly personality without it and so I know it isn't used and abused. [My loved one] needs the medicine, it’s how [their well-being] is managed so [they] can go out” and “[Our loved one] was seen by a specialist who changed [their] meds to stabilise [their] mood. [Our loved one] had some terrible medication changes by this consultant, who just changed it, a locum, without telling anyone why. There was lots of trouble, [our loved one] was so angry all the time. We then had a best interest decision with everyone involved and it's much better now. [Our loved one] is back on the right medication.” Professionals expressed their growing confidence in medicines management at the service. Comments included: “There seems to have been some issues with understanding of medicine administration, (timing/duration) but the home are addressing this, and I have worked with them to try to make sure directions on medications along with duration of treatment is included on prescriptions to support carers” and “There is a new system in place that supports to spot medication errors spontaneously. This helps to correct the error without delay. There is a community nurse that comes to the home to check the meds reviews and staff complete the medication audits once a week. Staff that administer the medication they complete the meds counts daily before administering and after administering.”

Staff told us they felt well supported regarding medicines management, and that they felt that the systems in place vastly improved. They told us they had training, and competency checks to make sure they gave medicines safely. They were able to describe how medicines errors or incidents were recorded and followed-up, and they knew the procedure to follow if people refused to take their prescribed medication. Comments include: “I support people with medication administration. For some of the [people] I have an idea of how they might respond. So, I might offer the medication basing on my previous experience with them of what they like. If they then refused their medication I would try again after a short while and a third time adding little distractions or incentives to aid their cooperation. If they still refused, I would ask another medication trained staff if they could have a try. If still a refusal I would let my [senior staff member] or person on duty know. Afterwards I'd ring 111 to let them know and get advice from them” and “If they continued to refuse it, I would contact the GP for advice or out of hours if the surgery was closed. I would document the refusal and monitor the individual for any effects of refusing the dose. I would document, monitoring the individual and contact for emergency medical assistance if I had cause for concern and inform my manager about all of the above.”

Safety of medicines administration and storage had been vastly improved with the development of a separate medicine’s storage room, complete with air conditioning to ensure a constant temperature. However, we found the provider’s medicine management policy had not always been followed, and there were still areas of medicines processes that needed to be improved. Audits and quality checks to ensure the proper and safe management of medicines were not always effective. Quality checks had not identified or addressed that personalised protocols were in place for all medicines prescribed ‘when required’ on provider’s electronic recording system, discrepancies in stock counts of a controlled drug for 1 person, or an expired box of controlled drug medication in the controlled drug cupboard. Stock checks of controlled drugs had not always taken place as planned and were not effective. This meant there was a risk of error. People’s medicines were not always stored securely, and we found the medicines storage room left unsecured during our site visit. We raised it with the provider, and they acted immediately to address and rectify these issues. Medicines were ordered, stored at the correct temperature and disposed of securely. Medicines records showed that they were given as prescribed for people. We observed staff giving medicines safely and in a kind and caring way, taking time with people, and asking if any ‘when required’ medicines were required. We observed people’s individual preferences for how they liked to take their medicines were respected by staff. Medicines incidents or errors were reported and investigated.