• Care Home
  • Care home

Mulberry Court

Overall: Requires improvement

Gold Hill East, Chalfont St Peter, Buckinghamshire, SL9 9DL (01753) 886613

Provided and run by:
The Fremantle Trust

Latest inspection summary

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Background to this inspection

Updated 23 July 2019

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Mulberry Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Mulberry Court accommodates 28 people across two floors each of which has separate adapted facilities. At the time of our inspection there were 21 people receiving care.

The service did not have a manager in post registered with the Care Quality Commission. However, the service had an interim manager who was managing the service until a new registered manager had been appointed. We were told following our inspection that a new manager had been appointed.

Notice of inspection

The inspection was unannounced on the first day.

What we did

Before the inspection we reviewed the information the provider sent us in the Provider Information Return (PIR). This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps us support our inspections. In addition, we reviewed notifications and safeguarding information that the service had told us about. Statutory notifications are information that the service is legally required to tell us about and included significant events such as accidents, injuries and safeguarding notifications.

During the inspection we reviewed each person’s medication administration record (MAR) and controlled medicine records. We looked at six people’s care records and documentation relating to the records such as food and fluid charts. In addition, we inspected four recruitment files, supervision records, the training matrix and other records relating to the way the service was run.

We spoke with the regional manager, the interim manager, the quality manager, the deputy manager, the assistant manager and several members of the care team. In addition, we spoke with the assistant chef, two visiting families and three people using the service. We completed a Short Observational Framework for Inspecting (SOFI). SOFI is a way of observing care to help us to understand the experience of people who cannot talk with us. We observed meal times and activities carried out.

Overall inspection

Requires improvement

Updated 23 July 2019

About the service

Mulberry Court is a residential care home that was providing personal and nursing care to 21 people aged 65 and over at the time of the inspection. The service is registered to accommodate 28 people.

People’s experience of using this service

We found medicines were not being managed in line with current best practice.

Some people had not received their medicines due to lack of stock. Systems in place had not identified the issues we found in relation to the management of medicines.

Staff received safeguarding training when they first joined the service. Staff we spoke with told us they knew what abuse was and they would report any concerns following the correct procedure. Relatives we spoke with told us their family member was safe living at Mulberry Court.

We looked at records of equipment checks such as slings used for hoisting people. Records of sling checks were not always completed to confirm checks of equipment had been carried out.

Staff did not always receive the training they needed to carry out their role. We saw several members of staffs training had expired. However, we saw the deputy manager had arranged for future training dates following our inspection.

Staff had not always received supervision and appraisals in accordance with the provider’s policy. Staff reported, “Although there have been several changes in management the ‘core group’ are still here. We all support each other.”

Some people were being deprived of their liberty for the purpose of receiving care and treatment without lawful authority.

Systems and processes in place, such as regular audits to assess monitor and improve the quality and safety of the service were not effective; they had failed to identify the issues we found during our inspection

Assessments of people’s needs were in place, and care and support were reviewed regularly and updated when required. People and their families had completed a life history this included information about choices and preferences.

A registered manager was not in post at the time of our inspection. However, an interim manager was managing the service until a new manager had been appointed.

People were treated with kindness and compassion. People and relatives praised the staff and said they were happy living at Mulberry Court. People were supported and treated with dignity and respect; and involved as partners in their care.

There was a wide range of activities for people to engage in and to follow their hobbies. The service encouraged people to take active roles in their community. For example, communities visiting the service including a local parish church, local cub scouts, primary schools and the pharmacy to enable people to buy gifts and cosmetics.

Rating at last inspection

At the last inspection the service was rated Requires Improvement. The report was published (23 March 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this report.

Why we inspected

This was a planned inspection based on the rating of the service at the last inspection.


We have identified breaches in relation to safe care and treatment, staffing, good governance and unlawfully depriving people of their liberty.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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