Mulberry Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood the importance of recording any accidents, incidents or near misses. These were reviewed by the management team and steps were taken to help prevent similar events reoccurring. This included making referrals to health professionals and discussions with people and their families to help promote people’s safety. Any additional measures introduced were clearly communicated to the staff team.

One staff member said, “The incidents are shared across the whole organisation as lessons learnt bulletins which are given to every staff member to read and sign.”

People using the service and their relatives understood how to raise concerns. They said the registered manager was approachable and they would not hesitate to speak with them should they have any concerns.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Prior to admission people and their families were involved in the pre-assessment process, where the registered manager gathered information to make the transition to a care environment an easier experience. Staff said, “When someone new arrives, I read their care plan and relevant risk assessments and listen carefully during handover so I understand their needs before providing care. If I am unsure about anything, I ask the senior member of staff.”

The team worked with healthcare professionals, including GPs and specialist practitioners, to monitor people’s health conditions and respond promptly to any changes in their support needs.

Effective systems were in place to share information with other services. People’s care and health records were kept up to date. Staff told us there was good communication at the service which ensured they knew about changes in people’s care and treatment. Essential information about people was readily available should they need to be admitted to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider understood their responsibilities to report any concerns and made referrals to the appropriate authorities in a timely manner. Staff had received training in how to recognise and report abuse and knew how to raise safeguarding concerns both internally and externally.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the service was working within the principles of the MCA.

One staff member said, “I have completed safeguarding training. It taught me how to recognise different types of abuse or neglect, including physical, emotional, sexual and financial abuse. I also learned that any concerns must be taken seriously and reported straight away.”

People we spoke with felt they were protected from avoidable harm. One person said, “I always feel safe here.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had access to clear and relevant information to support people safely. Risk assessments covered a range of needs, including skin integrity and falls. These were reviewed, and records showed people using the service and, where appropriate, their relatives were involved in the review process. One relative said, “The communication is very good here. They discuss everything with us and ask our opinions.”

Guidance and instructions from relevant healthcare professionals to reduce health risks were clearly documented and followed by staff. One professional said, “Staff here know their residents. We are always given an update, and communication with them is very good."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, comfortable and generally well maintained. Staff completed regular visual checks of the environment to make sure it was safe and free from hazards. Staff were confident to raise any safety issues with the management team. The providers were responsible for undertaking routine maintenance. Essential servicing had taken place of moving and handling equipment and fire safety equipment. Staff practiced fire evacuation to ensure they were competent and they knew what to do in the event of a fire. Personal emergency evacuation plans had been agreed with people to support them to evacuate their home safely in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were safely recruited by undertaking necessary checks, including on their previous employment, conduct and any gaps in their employment history were explored. Disclosure and Barring Service (DBS) checks were completed before staff could work alone. DBS checks provide information including details about convictions and cautions held on the Police National Computer. All these checks help employers make safer recruitment decisions.

There was a consistent staff team which helped to ensure continuity of care. Staffing levels were regularly reviewed to ensure there were enough staff on duty to meet people’s changing needs. The provider’s dependency tool identified that there were sufficient staff. However, feedback from staff and people was mixed. One person said, “If I need to press my buzzer [which I don’t very often] it depends on how many staff are on how quickly someone comes. They are a bit low on numbers at the moment.” Staff said, “The staffing levels have become somewhat inadequate.” However, another person said, “They have always answered my needs.”

The provider received feedback about staffing concerns and provided evidence of recent recruitment and funding for additional care hours.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The premises were clean and free from unpleasant odours, which was confirmed by relatives and health professionals. Staff had received infection prevention and control training and we observed them using protective equipment (PPE) such as gloves and aprons which were situated around the service.

Housekeeping staff were clear about their roles. They explained there was a daily cleaning schedule including deep cleaning of people’s bedrooms took place when a person was ‘resident of the day’. Relatives told us the home was clean when they visited. One relative commented, “It is always clean and tidy."

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines stocks were checked regularly to ensure people’s medicines were ordered in advance. Staff had received training in administering medicines and their competency assessed. The service had discussed people’s ‘when needed’ medicines with their GP to ensure there was clear guidance for staff on when they should be administered. Staff were guided to which area of a person’s body topical creams should be applied.

Medicine administration was regularly audited to ensure best practice guidance was being followed. This included checking medicines with a short shelf life were in date, and that they were kept at the correct temperature. This meant people were kept free from harm.