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

We found 3 breaches of the legal regulations. Quality assurance systems were not robust and did not operate effectively in helping to ensure people consistently received good quality care and support. Processes were in place to ensure the provider operated safely but they were not always effective. The service was not effectively monitored to ensure continued learning and improvements. People told us that the provider was not always well-led. Leaders and managers did not always engage with staff, people who use the provider, their relatives and other stakeholders to shape its culture. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. At the time of our inspection there was not a registered manager in post. A new manager had been in post for five months and intended to submit an application to register with us.

This service scored 64 (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. The cover arrangements organised by the provider and nominated individual did not always ensure consistent leadership. Staff did not always feel supported and empowered and this put people at risk of poor outcomes. Staff did not always feel appreciated, or able to speak up. Comments from staff include: “I regularly feel like I can never do enough, as far as I understand, management has very hectic jobs and always has deadlines to reach and goals to meet. It seems that staff never get any recognition for the work they do, especially when they have taken the extra mile” and “[Previous] manager seemed great when they first started at Mulberry, but over time they took on another home and was hardly at Mulberry Court, so things weren't getting done and that frustrated not only staff but the people we support.”

The provider had policies and procedures about upholding people's rights and making sure diverse needs are respected and met, but these were not be fully understood or consistently followed. Support for staff from managers was inconsistent. Managers and staff did not always share and understanding of the risks and issues facing the provider and were not always clear about their roles and responsibilities.

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.

Management at Mulberry Court had gone through a period of change since the last inspection. The manager was in the process of applying to be registered manager with CQC. Managers were not always supported by their leaders. Comments included: “I didn't have a proper induction. I was told here you are, off you go. Everyone in the region was 4 hours away. I have a new line manager and it's better now.”

Quality assurance systems were not robust and did not operate effectively in helping to ensure people consistently received good quality care and support. Governance and performance were not always reliable and effective. Accident and incidents records were not always complete and were not 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. Care plans were not updated to provide staff direction as to how to support people in times of distress or in an emergency. Lessons learnt had not been identified or shared with staff to prevent re occurrence. Monthly quality audits were completed but were ineffective and failed to identify a number of issues which meant that risk to service users were not always assessed and mitigated putting them at increased risk of harm. For example, monthly quality audits failed to identify shortfalls around staff failing to escalate medical emergencies such as high blood sugar levels readings to health professionals. We found no evidence of audits of skin integrity and wounds or daily care recording for example turning and positioning. Audits at a provider level had not identified the shortfalls found within the inspection. For example, the internal quality assurance inspection failed to identify medicines management shortfalls we found at this inspection. It also failed to identify the risk associated with the administration of blood thinning medication had not been identified or mitigated. Similarly, it failed to identify the risk associated with the use of potentially flammable creams had not been identified and mitigated.

One person told us: "Staff go to the doctors with me, when I need to go they would go with me. But I can go on my own." Relatives commented: " I do know that [my loved one] goes to the hygienist regularly and I believe a chiropodist comes to the home to cut [their] and the other residents nails although I haven’t seen [their] feet lately" and "I discovered that the [previous manager] had registered my [loved one] with the [local charitable organisation] in 2021 but there didn’t seem to have been follow-up, probably because of post-pandemic. However I have reached out to the charity who have now visited [my loved one] and as experts on managing [health condition] as well as disability, their local volunteer is going to add their support to [my loved one] alongside the Mulberry Court staff."

Staff told us: “Sometimes staff will support [people] to book train tickets or taxis. If they ever need an appointment to be made staff will ring and make the appointment for them. Families are encouraged to visit as often as they can/like.” One healthcare professional commented: “[People] are brought for appointments and health checks very kindly by the staff to prevent too many home visits.”

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. Legal requirements were not always met. Statutory notifications had not been submitted as required. One healthcare professional told us: “[One person] suffers severe [health condition] and was administered medication by their relative daily at home. The manager said this would not be allowed to continue at Mulberry Court due to safeguarding reasons in the home. The District Nurses did not have the capacity to attend daily to administer so we had to find a work-around solution. I was not certain whether the manager was interpreting the rules correctly that [their relative] could not administer their medication to a [person] with capacity to ask for this. [Person] preferred [their relative] to do it.”

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. The provider was not always collaborative and cooperative with external stakeholders and other services. It did not always shared information and best practice effectively. There was a limited approach to obtaining the views of staff, people who use services and their relatives, external partners, and other stakeholders. Feedback was not always reported or acted on in a timely way.

The manager told us: “We are working very closely with the local authority to complete the service improvement plan. We had a mammoth training [improvement program] through December and January. I have autism training coming up for the team. Training compliance is very good. Staff have six months for all training, three months for mandatory. The face-to-face training since December has been incredible” and “I am very appreciative of your feedback. You never stop learning.”

Quality assurance processes were not always applied consistently and were not always effective. Management and staff not always understood the principles of good quality assurance. Staff were not adequately supervised, and service had high staff turnover. Evidence of learning was applied inconsistently, there was no evidence reflective practice or evidence that improvements have been embedded in practice. Accident and incidents records were not scrutinised by the manager or the provider. Lessons learnt had not been identified or effectively shared with staff to prevent re occurrence. Care plans and risk assessments had not always been updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support. Management systems did not effectively identify and managed risks to the quality of the service. When risks were identified, they were not always used to drive improvements in a timely manner. For example, provider’s internal quality assurance inspection found the service to be unclean and in need of redecoration with walls and doorways seen to be damaged by wheelchairs. During our inspection we saw 3 people’s bedrooms required cleaning, bedroom furniture was broken, and sharp metal exposed in 2 people’s bedrooms The toilet in the communal bathroom in bungalow 1 was leaking and out of order yet still accessible for people, cleansing wipes were stored on the radiator. The communal shower room in bungalow 1 had paint peeling off the ceiling. This placed people at ongoing risk of the injury and spread of infection.