Mulberry House

About the service

Mulberry House is a residential care home providing personal care to 8 people at the time of the inspection. The service can support up to a maximum of 8 people.

People’s experience of using this service and what we found

Right Support:

People did not always receive safe care and support, and the environment was not always safe or clean. People’s needs and preferences were not always met.

Risk assessments were not always in place to assess known risks.

People were not always supported to pursue their hobbies and interests. We did not see evidence that people were engaged with regular in activities of their choice

Staffing levels within the service were safe, and medicines were managed safely

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff supported people to access health and social care services.

Right Care:

People did not always receive care that was person-centred, and people’s goals and activities were not always well documented. Staff were not always proactive in engaging with people in activity.

Staff understood safeguarding procedures. Staff had training on how to recognise and report abuse and they knew how to apply it.

People's care plans reflected their needs and wishes and promoted their wellbeing.

Right Culture:

The ethos and values within the service did not always promote good standards for people.

Systems and processes were not effective in picking up and responding to any problems within the service.

There was a poor morale within the staff team who told us that issues were not addressed, and communication was not good.

People and those important to them, including social care professionals, were involved in planning their care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update.

The last rating for this service was requires improvement (published 27 June 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mulberry House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, person centred care, and good governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Mulberry House is a residential care home that was providing personal care to seven people at the time of the inspection.

People’s experience of using this service:

People’s relatives told us their relatives were happy living at Mulberry House. People looked relaxed and comfortable with staff.

When we inspected in February 2018 we had concerns about the management of the service. When we inspected in October 2018 we saw that some improvements had been made, but we still found issues in relation to the environment, the culture of the staff team and how the provider was assessing the quality of the service.

At this inspection in May 2019 we saw that some improvements had been made. The home now had a registered manager. Although, staff still did not have effective support and direction when supporting people. Staff competencies in their work were not being monitored and checked. We found shortfalls in how staff interacted and supported people. The training and support staff received was not effective in enabling staff to perform well in their role. The management team were aware of this issue, but work had not been completed to address this. The provider had not identified this issue and created a plan to address this.

There were now some events and outings taking place. Activities were also happening. However, staff were not communicating effectively with people. Staff and the management team were not identifying and helping people realise their interests.

Staff had a good understanding of what potential abuse looked like and what they must do about it. Accidents and incidents were managed. However, we found shortfalls in how one situation was dealt with by the management team which did not promote this person’s safety and rights at this time.

People had risk assessments and care plans in place. However, we found that some risks were not fully explored with good plans in place for staff to follow.

People received their medication as prescribed. Staff sought assistance from health professionals when people needed this support. Routine health appointments were made for people.

The meal experiences had improved, and people were being offered choice which was individual to them. Healthier foods were offered and made available for people. People enjoyed eating the food and snacks provided although staff struggled to engage with people during their meal experience. Healthy life styles were not promoted or encouraged, plans to support people to try and be more active were not in place.

The management team and the provider had made improvements to the environment. This had been a concern identified at previous inspections. Rooms had been painted, curtains and blinds purchased. Furniture had been mended and replaced. The registered manager told us about plans underway to improve the environment further for people.

Audits and quality checks by the provider were not always effective at identifying areas of improvement. Robust action plans were not in place to support the registered manager to make further improvements.

There were breaches in the Health and Social Care Act 2008.

This service has been in Special Measures. Services which are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Rating at last inspection:

Requires Improvement with Inadequate in Well Led. This was published in November 2018.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

Ongoing monitoring;

We will await the action plan, review this, and inspect the service again to check the improvements have been made.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

At the last inspection we found an inadequate level of leadership at the home, fire safety checks were not complete, plans to promote people’s safety were also not complete. Safety checks on new staff to ensure they were safe to work at the home were not taking place. There were low levels of staff on shift. Staff were working long hours despite supporting people with high needs and often with low staffing numbers. Staff training was not effective. There were institutionalised practices in relation to people having drinks. Healthy food was not available. People whose weight was low were not being supported to increase their weight. The environmental condition of the home was poor. People were not being supported to explore their interests. There were no regular social events taking place. The provider was not completing meaningful and effective audits.

We inspected the home again six months after the report was published. We found some improvements had been made. However, there were still areas which required further work. Where improvements had been made further time was needed to see if these improvements were effective, sustained and embedded into the culture and practice of the home. Further work was also needed in terms of the culture of the home.

The overall rating for this service is now ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This service has therefore remained in special measures.

When we inspected the service on 11 October 2018 we rated the service as ‘Requires Improvement’ overall. This inspection was unannounced.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Mulberry House provides personal care and accommodation for people who have a range of learning disabilities. Mulberry House can provide care for up to 8 adults. At the time of the inspection 8 people were living at the home. Mulberry House comprises of accommodation over two floors.

The care service had not been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy. However, some progress had been made to start to develop the service in line with these values.

There was not a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider was recruiting for this post.

At this inspection we found some unsafe practices in relation to how infection control was managed at the home. The storage and disposal of people’s medicines were not always being managed appropriately. People’s safety in and outside the home was not being consistently promoted by staff actions and by effective risk assessments and plans. Incidents, accidents, and a safeguarding event were not always being managed in a way which ensured people were safe. Lessons were not being learnt from these situations to protect people’s safety in the future.

Staff were not consistently kind and respectful to people at the home. The provider was not always valuing people at the home by promoting standards in their environments.

Plans had been put in place to improve the leadership of the service and day to day management oversight of the home. However, the provider had not provided appropriate temporary management cover while there was no registered manager in post. Given the changes needed at the home more management support and presence was needed.

Quality monitoring audits by the provider had improved but they were still not robust checks identifying flaws in staff practice, and risks to people’s safety. Still the upkeep and maintenance of the home environment was an issue. The provider was unable to see short falls in this area and act to resolve them. This made us question the values of the provider in respecting people at the home and their ability to promote their rights.

These issues constituted repeat breaches in the legal requirements of the law. There was a repeat breach of Regulation 12, 10, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of the report.

Following the last inspection there were more staff on shift to meet people’s needs. Staff told us that the quality of the training had improved. Although, there was no longer a registered manager in place staff spoke positively about the current leadership of the service. Staff found that the provider visited more frequently and they were approachable.

Staff knowledge about how to protect people from abuse and discrimination had improved, but further work was still needed in these areas.

Staff now had a clear understanding about how to promote choice and people’s freedoms.

The service was starting to look at promoting healthy food options. More work was required in how they promoted people’s meal experiences and choices of meals and drinks.

People had experiences of activities and events with some planned trips taking. The leadership of the home were starting to ask people about what they wanted to do and find ways to broaden people’s interests and wishes.

We inspected this service in January 2016 and rated the home as Good overall. When we inspected the service on 1 and 2 February 2018 we rated the service as Inadequate overall. This is the first time Mulberry House has been rated as Inadequate overall. This inspection was announced the day before we visited. This was to ensure a member of staff would be present to let us into the home.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Mulberry House provides personal care and accommodation for people who have a range of learning disabilities. Mulberry House can provide care for up to 8 adults. At the time of the inspection 8 people were living at the home. Mulberry House comprises of accommodation over two floors.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

When we visited the home we found there were issues with how the service promoted people’s safety. Timely action was not taken to repair some fire safety equipment. Checks to ensure people were safe in the presence of staff were not always completed or in a robust way. There was a lack of clear leadership at the home. Posts relating to the leadership of the service remained vacant with no plan in place to respond to this issue.

The provider (owner) had not responded in a timely way to requests from the registered manager about making improvements to the home. They did not show a commitment to help the service to make improvements. The building looked uncared for in places. There were delays in making real plans to improve the home. This made us question how the provider valued the people living in the home.

The quality monitoring audits were not robust. We had not always been informed about the important events which we should be notified about, by law.

Staff did not receive competency checks to ensure they had the skills and knowledge to do their work. Staff were critical in how their training was delivered and the registered manager and provider were not checking if the training was effective. Not all staff received regular and complete training.

There was a lack of activities which people engaged with at the home, although the home was starting to work on this issue. There were no planned events and people were not being supported to realise their ambitions and interests.

These issues constituted a breach in the legal requirements of the law. There was a breach of Regulation 12, 19, 18, 10, 9, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was also a breach of the Registration Regulations (18). You can see what action we asked the provider to take at the back of the full version of the report.

Staff did not have a clear understanding about the process they could follow in reporting potential abuse and harm outside of the home. Staff also did not know how to fully respond if people experienced discrimination. There were no clear systems in place to support staff to respond to these potential situations which also promoted people’s rights at the home.

People received their medicines as prescribed and people were supported to access health appointments. People had risk assessments in place but these were not always up to date and did not fully explore the risks which people faced. With a plan of action to follow to mitigate and respond to these risks.

The home did not always promote healthier foods and lifestyles at the home. People were not always supported to drink frequently during the day.

Staff were promoting people’s freedom of choice but this was not done for all the people in the service. For some people, staff were also potentially restricting their liberties and rights at the home.

The staff at Mulberry House were kind and caring towards the people who lived at the home. Staff spoke with people as adults and the service made attempts to encourage people’s independence with their day to day needs.

Staff and the registered manager spoke about their commitment to the service. The registered manager told us that they were motivated to make improvements.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records.

We found that the home was meeting all areas.

If you wish to see the evidence supporting our summary please read the full report.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic. The home had been well maintained. There were enough staff on duty to meet the needs of the people living at the home and a senior member of staff was available to provide support. Staff we spoke with told us that the home was 'doing well', and staff were 'able to get involved' with the planning of care. One staff member told us that the best thing about the home was 'the way we care for people'. We could see whilst at the service that people were happy and enjoyed the company of the care staff.

Is the service effective?

When we entered the home we were approached by people living in the home, they were keen to tell us about the home and their past experiences. We noted that another person was waiting to go out with a staff member but was worried about money and staff were spending time reassuring them. One person we spoke with said that they regularly spent time with the care staff and enjoyed it. We observed that people were singing in the communal seating area and staff encouraged them and joined in. We observed that people were happy and even those who were in their rooms were also regularly involved in conversations and staff spent time with them. From reviewing the care documents and observing staff with people we saw that they had a good understanding of the people's care and support needs.

Is the service caring?

People were supported by kind and caring staff. We saw that staff encouraged people to sing and enjoy themselves and also participated with them. Staff spent time with people in their rooms and when asking questions waited patiently for responses. We saw one person was sitting in their room and the lighting was dim so they were straining to read. We observed that staff entered the room after gaining permission and then asked the person if they would like the lights on so they could see better. Staff did not just switch the lights on without asking. Staff told us that they provided people with person centred care. We observed that care staff were patient with people.

Is the service responsive?

Care plans were regularly reviewed and updated according to the person's needs. Each care document provided staff with clear information about the person and the care they required. Staff told us that since the care documents had been updated 'grey areas were now being picked up' and that the care plans 'help us to get to know the clients better'. Staff were aware of people's needs and preferences and acted in accordance with their wishes.

Is the service well-led?

Staff told us that the home had 'come on loads' since the last inspection. We were told that care staff were 'able to get more involved' with the care planning. Staff told us that the management of the home was supportive and proactive. We were told that staff were encouraged to 'speak out' if there was an issue and that the manager 'always listens' and acts on the concerns raised by staff. For example we were told that staff asked for the carpets for the communal lounge to be replaced because they were worn and dirty and the manager arranged this. Staff told us that they enjoyed working at the home and were given time to spend with people.

The provider employed 10 staff in this home, and we noted from records that recruitment processes were robust, and appropriate checks were undertaken to ensure they were suitable to work in this environment.

We noted people who used the service were encouraged to make choices about how they spent their time, and where able, people consented to the support they received. However where people lacked the capacity to make decisions, this had not been formally assessed.

There were care plans in place, however due to the transition to new documentation, these were inconsistent and could be confusing for staff. However the staff that we spoke with were knowledgeable about the people they supported, and knew how to meet their needs safely.

We found that people received their medication as and when it was required, however where topical medication was prescribed, there were no records to confirm they had been applied appropriately.

The quality and safety monitoring systems were insufficient to ensure all areas of risk were swiftly identified, monitored and managed.

We looked at records relating to complaints and safeguarding, and spoke with staff about the systems that were in place to protect people in this regard.

We found the provider had reviewed their systems and made changes to strengthen the existing processes to protect people. These changes had been clearly communicated to staff, and we could see from the financial records of people using the service and the complaints file, that staff were following new guidance and these changes had been effectively implemented.

There was a relaxed atmosphere in the home and people were at ease in the company of the staff supporting them. The staff were friendly and polite in their approach and interacted confidently with people.

We observed some positive interaction between care staff and people using the service, which showed that staff understood the needs of the people they were supporting. We saw that people were offered support at a level which encouraged independence and ensured their individual needs were met. One person told us "The staff look after me well, They have taught me a lot of things since I have been here."

The provider had appropriate policies and procedures in place, however with regards to safeguarding they had failed to report matters consistently, or maintain clear financial audit records. With regards to concerns and complaints we found there were no records to show how these matters had been investigated or resolved.