• 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

All Inspections

3 June 2019

During a routine inspection

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

30 January 2018

During a routine inspection

The inspection took place on 30 January and 1 February 2018 and was unannounced.

Mulberry Court is a ‘care 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 Court accommodates 28 people in one adapted building. The care home accommodates people across two separate units, each of which have separate adapted facilities. Four bedrooms can accommodate doubly occupancy. Both of the units specialises in providing care to people living with dementia. At the time of our inspection there were 24 people using the service.

The service requires a registered manager to manage the service. 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. There was a registered manager in post at the time of our inspection.

People were protected against abuse and neglect. Staff we spoke with were knowledgeable of the process to follow if they suspected abuse had occurred. People told us they felt safe living at Mulberry Court. One person told us, “I’m safe everything is jolly here.” One relative told us, “My [mother] receives extremely good care and love in here, I cannot fault them.”

Recruitment of staff was safe and ensured only suitable people were employed. Staff received training support and appraisal. Supervisions were carried out on a regular basis. Staff told us they felt supported and worked as a team and they all helped each other. The service was managed by a person described as approachable and positive. We saw the registered manager was available and ‘hands on’ and assisted staff when required. The culture of the service was open and transparent. Relatives told us the service was well managed.

People and their families had the ability to voice their concerns and had regular ‘residents and relatives’ meetings where they could discuss any issues or concerns they had. Complaints were responded to with outcomes. We saw complainants were kept informed of the status of the complaint.

Medicines were not always managed effectively and were not always available for people. This meant people could be at risk if medicines were not taken as prescribed by the GP. We saw several people had been without their medicines on several occasions. Homely remedies were given without following the correct guidelines and procedure.

Risk assessments were in place for most people’s needs. However, some people who were at risk of poor fluid intake did not always received adequate fluids to prevent dehydration.

We observed staff were kind and caring and were able to spend time with people. People and relatives told us staff were kind and nothing was too much trouble for them. We observed there to be adequate staff available to meet people’s needs.

The service followed the requirement of the Mental Capacity Act 2005 (MCA). The recording of consent and best interest decisions meant the service complied with the MCA codes of practice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People told us the food was good and they had a choice of menu. We were told the food was fresh and sourced from local suppliers. We observed the lunch was served in a calm way and people could sit and chat with each other after lunch. However, we saw that when people were at risk of malnutrition and were losing weight the correct procedures were not followed.

The premises were cleaned to a high standard we saw domestic staff on both days of our inspection engaged in cleaning duties. Rooms and communal areas were in good state of décor bed linen was clean and of good quality, rooms were clean and tidy, hoisting equipment was stored safely and corridors were hazard free enabling people to walk freely around the premises.

Audits were carried out to monitor the quality of care at the service. However, medicine audits identified several people had not received their medicines over a period of time. Actions had not been taken to prevent continued periods where stock was insufficient.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

9 April 2015

During a routine inspection

This inspection took place on 9 April 2015 and was unannounced.

Mulberry Court is a care home providing accommodation for up to 28 people who require personal care. This may include people living with dementia, older people or adults under 65 years of age.

At the time of the inspection 24 people lived at Mulberry Court. This was the first inspection of Mulberry Court since it was registered with the Care Quality Commission (CQC) in December 2013.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

People were positive about their safety and security. Potential risks to people’s safety were identified within their care plans. For example, from falls. Action was taken to address this, falls risk assessments identified the number of staff and equipment required to move the person safely.

The interaction between staff and people living in the home was polite, respectful and friendly. There was a very relaxed atmosphere throughout the home and staff had time to talk informally to people in lounges and dining areas. People said there were sufficient staff available. We checked staffing rotas and found in the majority of cases they agreed with the set staffing structure. People said they experienced a good level of staff consistency which was positive for them.

Staff confirmed they received regular training to enable them to meet people’s care needs. Domestic support staff confirmed they had received infection control training and training about the safe use and storage of chemical products.

Staff confirmed there was a mixture of formal and informal supervision, together with an annual appraisal. There were staff meetings and staff told us they had the support they needed as they also had the opportunity to discuss any issues with their line manager or the registered manager at any time.

Staff had received safeguarding adults training and this was confirmed from training records. There was safeguarding information and contact details displayed prominently in the home for staff and others to refer to in the event they saw or suspected abuse had taken place.

Care plans included evidence of pre-admission assessments to identify individuals’ care needs. This enabled, for example, any specific equipment required to be put in place before the person moved in and ensured their needs could be met from the outset. Staff followed any advice and recommendations given by healthcare professionals involved with the service, for example GPs and specialist nurses. They provided very positive views of their interaction with the service and the quality of care and support they observed.

Medicines were administered safely. Routine checks were carried out to monitor records and practice to make sure people received safe and effective support when they needed help with their medicines.

Relatives confirmed they had completed questionnaires and had also met informally with the registered manager to discuss their relative’s care and provide feedback. People were positive about the leadership of the registered manager and told us they were; "Effective and approachable".

Staff had a good understanding of the implications for them and their practice of the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make specific decisions at a given time. DoLS provides a process by which a person can be deprived of their liberty when they do not have the capacity to make certain decisions and there is no other way to look after them safely.