Mulberry Court

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• 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

There was lack of consistency in how well the service had been managed and led. The leadership, governance and culture had not supported the delivery of high-quality, person-centred care. Legal requirements were not fully understood and met. Leaders were not always alert to examples of poor practice and culture that may affect the quality of people’s care. Governance, management and accountability arrangements were not reliable nor effective. Quality assurance arrangements were not applied consistently and were ineffective. Management systems were in place to drive improvements. However, these had not identified and managed risks to the safety and quality of the service found at this inspection. Actions to introduce improvements were reactive, not applied widely and consistently across the service, often focused on the short-term solutions and not effectively reviewed. The culture of reflective practice, continuous learning and service improvement was not fully embedded and was not sustainable. The culture of the service had not always been open and transparent. Data and notifications were not consistently submitted to external organisations as required. For example, safeguarding concerns were not always reported to the local safeguarding team following incidents where people had been at risk of potential abuse. Leaders and managers did not fully engage with staff, people who use the provider, their relatives and other stakeholders to shape its culture. People, their relatives and staff told us the service was not always well-led and there was high turnover of staff and managers. Most recent change in manager’s post led to improvements in training delivery, supervision and the support they received. However, not all staff understood their roles and responsibilities. At the time of our inspection there was not a registered manager in post. A new manager had been in post for 3 weeks at the time of inspection and intended to submit an application to register with us.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Support for staff from managers was inconsistent due to a lack of a registered manager at the time of our inspection. Staff told us the service had experienced lots of changes in the manager's post, which had led to a period of instability and low staff morale. We received negative feedback from staff about the previous management of the service. However, staff spoke consistently highly of the new manager. Staff told us they felt supported and appreciated by the newly appointed manager and were encouraged to speak up. Comments included: “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 didn't feel appreciated by the old manager, I actually emailed [ manager’s name] at the time wanting to leave. I'm glad I stayed now [manager’s name] is here. The new manager is very easy to talk to and has an open-door policy where we can talk openly about any concerns. If there's a problem [they] want to know and [they] do immediately talk to the people involved”, “The management team as a whole regularly remind staff of their appreciation of their hard work and dedication to the service. It has been recognised that the service was previously struggling but reinforce staff morale with regular improvements.” Management expressed: “The priority was nurturing the staff team - getting them to work together, feel reassured. Build skill set of seniors, nothing had been explained to the staff and it was important to make sure they knew what we needed to do, what we needed to achieve. Changes don't happen overnight but some things like organising the meds was important because you couldn't see the wood from the trees.”

The provider did not have a fully supported management structure. Systems in place did not always effectively monitor the quality of care provided to drive improvements. The manager had a good understanding of CQC requirements, in particular, to notify us, and where appropriate the local safeguarding team, of incidents including potential safeguarding issues, disruption to the service and serious injury. However, this knowledge had not always been applied into practice. Managers and staff had not shared an understanding of the risks and issues facing the service and were not always clear about their responsibilities. Reporting of incidents, risks, issues and concerns was unreliable or inconsistent. Cover for absent managers had not ensured consistent leadership. This was a repeated breach of regulation. Although staff expressed positive comments about current leaders, at the time of the inspection there was still instability within the leadership of the service and therefore there was no established management structure in place at the time of our inspection.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff commented on frequent changes in manager’s post: “Working at Mulberry Court has been slightly tumultuous over last 3 years. I now work under ‘Manager No 3’ and ‘Deputy Manager No 2.’ Regular supervisions have always suffered but there is a real desire to get back on track with those.” Staff felt hopeful for the future of the service improvements with the new management team in place. Comments included: “We have lots of enthusiasm and are dedicated to make a difference. I think the staff and residents have just lacked management support and felt let down in the past by the changes in managers, they need some consistency”, “The new manager hasn't been there a long time nor has the deputy manager. The senior support workers seem to be doing a lot more of what was traditionally the job of the deputy manager, and it feels they are doing a really good job. They are visible on the floor and can be targeted with questions. The management above that are still getting to know the place, the people” and “I strongly believe that Mulberry Court is about to turn a corner. It has an amazing team on the floor and now with the new management team will go from strength to strength.”

Improvements were made to the governance systems within the service. However, they were not robust and did not identify shortfalls found during this inspection. Processes were in place to ensure the service operated safely but they were not always effective. Quality assurance systems did not operate effectively in helping to ensure people consistently received safe and good quality care and support. For example, quality assurance systems had failed to identify safeguarding incidents and had not ensured safeguarding incidents records were accurate to monitor and mitigate risks. Due to safeguarding incidents records being inaccurate, it was not possible to identify trends and themes in safeguarding, therefore measures could not be actioned to mitigate future risks. Audits at the provider level had not identified the shortfalls found within the inspection. For example, we found no evidence of audits of behavioural monitoring reports being completed for all people using the service. In addition, we found a behavioural monitoring report with a safeguarding incident that had not been identified by the quality assurance processes or reported to the local safeguarding team. Audits had not resulted in a continuous and sustainable improvement in the service or action to manage risks and ensure service users were safe. For example, a nutrition and hydration audit identified 8 people had lost weight since the previous audit. No actions were identified as a result of this findings. There was no management oversight of audits completed by senior staff members when audits had not identified any actions. This meant that provider’s quality assurance processes did not operate effectively, opportunities for improvement and development were missed, and people remained at risk of harm. This was a repeated breach of regulation.

Systems used to engaged with people, communities and partners were not always effective to identify new or innovative ideas that could lead to better outcomes for people. The service had not involved people, their family, friends and other supporters in a meaningful way. We were not assured people were always consulted about all the decisions regarding their care and support. Those who were involved had been the ones with a stronger voice. Relatives including people’s legal representatives, told us they were not always involved in creating and reviewing people’s care plans. Relatives commented: “We have been involved in [our loved one’s] care plan review in the past, but there has not been a care plan review recently involving us", "We noticed in the past [staff] were not fully engaged in an activity we had organised and brought it to [manager's] attention and we know they are now much more attentive" and “The new deputy manager who joined earlier appears to be an asset to the home as [they] are experienced in organising events and activities for residents, which had been lacking.”

The manager and staff felt comfortable to access support of visiting health and social care professionals when needed. Staff told us there had been improvement in partnership working: “I believe that significant improvement has been made in this area between Mulberry Court and external bodies that we communicate with on a regular basis. We have built bridges, formed close working relationships and bonds with our visiting medical professionals including OT’s, nurse practitioners, physiotherapists, social workers, LA teams, families and friends, safeguarding teams, and other multidisciplinary agencies. We have developed relationships with community-based activity groups, and this is going from strength to strength now that we have staff on board who are local to Gillingham and the service and who are using their contacts to build on activities for people on a more local level. Medical professionals that visit people on a regular basis including, physiologists, psychiatrist input, social workers, and GP practice resources” and “I believe communication is pivotal, as is openness and transparency. You must understand the boundaries that organisations must adhere to, however if you work in partnership effectively then the best outcome for the individual being supported is achieved.”

We received positive feedback from health and social care professionals working with the service. They told us there had been recent improvements in partnership working. Comments included: “The new management team have really improved the service and structure. On my visits, the home appears to be being led well with residents the main focus” and “On my visits l have seen the service that is progressing in meeting the needs of the service users. I have spoken to new manager on the phone, and [they] explained that [they] are learning new role through the most experienced staff around [them] at Mulberry Court.”

The service was not always transparent and open with external stakeholders and had not always shared information and best practice effectively. The provider did not always react sufficiently to risks identified through internal processes, but often relied on external parties to identify key risks before they start to be addressed. Referrals to the local safeguarding team following incidents where people had been at risk of potential abuse were not always made. This meant external scrutiny was not possible to ensure people were safeguarded from abuse.

We received positive feedback from staff about their involvement in developing and evaluating improvement and innovation initiatives. Staff felt this had improved recently with the new management team in place. Comments included: “I feel supported and my views I put forward to help the service and the people we support are actually taken into account and we now get senior meetings to air our opinions which we didn't before. 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. Our old manager didn't like the seniors doing the supervisions but equally [they] not keeping up with it so I don't feel like I've had as many as I should due to the old manager”, and “Although [manager’s name] has only been here a short period of time there has already been a vast improvement in communication within the service, staff are more comfortable to raise concerns and voice opinions. [Manager’s name] had provided the service access to successful improvements, [they] had taken staff opinions on board and worked in a way to improve the service not just the management team.”

We were not assured the service was effectively monitored to ensure continued learning and improvements. Accident and incidents records were not completed consistently and were not effectively scrutinised by the manager or provider. This had placed people at risk of not having their care needs identified or risks of harm identified to prevent a re-occurrence. Quality assurance processes were not always applied consistently or broadly and were not always effective. Management and staff had not always understood the principles of good quality assurance. In the past leaders had not always encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. However, there was a strong sense of trust developing between new leadership and staff. Staff and leaders had not consistently demonstrated a good understanding of how to make improvement happen. The approach was inconsistent and had not always included measuring outcomes and impact. There were processes to ensure that learning happened when things went wrong, and from examples of good practice however they were not always effective. Culture of reflective practice and collective problem-solving was not fully embedded. Improvements were not always identified, and where they were, action was not always taken or identified shortfalls were not always rectified in a timely way. Lessons learnt had not always been effectively shared with all staff to prevent re-occurrence. Care plans and risk assessments consisted of conflicting information, and we were not assured people’s records were always updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support. For example, people’s care plans were not effectively reviewed and updated to provide staff direction as to how to monitor people’s emotional well-being and support them in times of distress. This was a repeated breach of regulation.