Mulberry Court

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff worked with a shared purpose, supported by policies and values that promoted equality, diversity and person‑centred care. The provider’s statement of purpose emphasised dignity, compassion, empathy and supporting people to retain as much control over their lives as possible. We saw staff demonstrating these values in practice, interacting with people with kindness and empathy. There was a positive culture where staff understood what was expected of them and worked in line with the service’s aims.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service was supported by capable, visible, and compassionate leaders who demonstrated a clear commitment to driving improvement. The registered manager knew everyone well, which was clear from how easily people and families chatted and interacted with them.

Staff generally spoke positively about the registered manager. They said they felt well supported in their roles and confirmed they received regular and relevant training and supervision for their role to ensure they worked safely. Staff said, “I feel the manager is approachable and fair. I feel comfortable asking questions or raising concerns.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a whistleblowing policy in place with clear lines of escalation for staff concerns. This policy also detailed external contacts including CQC for staff to raise concerns if they felt they wanted to. One staff member said, “I feel able to raise concerns with my manager or senior staff, especially if someone’s safety or wellbeing is involved.”

Family members we spoke with told us they know who the registered manager was and they were approachable and sociable. Staff told us they felt they could raise concerns with the registered manager if needed and they would be resolved.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were policies in place to promote equality, diversity and inclusion. Training records demonstrated that promoting understanding of equality and equity for people was part of their mandatory training practices. Staff told us these policies were followed at the service and that they were treated fairly. Reasonable adjustments and adaptions had been made as needed. Most staff feedback was positive and included, “[Manager] is very supportive and treats everyone the same. She is very fair.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had systems to manage risk, monitor quality and support continuous improvement. Where issues were identified, action was taken to address these, and progress was reviewed. A structured service improvement plan outlined clear objectives alongside defined actions and timescales for completion, to ensure progress was effectively monitored and achieved.

We saw evidence of effective auditing across the service. This was overseen by senior staff, though all staff were clear about their roles in ensuring standards were met. This was recorded with actions noted where required and followed up.

The registered manager understood their responsibility under duty of candour to be open and honest when things went wrong. Notifications of accident, incidents or safeguarding concerns were submitted in line with legal requirements.

Feedback from staff and people who used the service was an integral part of the governance of the service. One staff member said, “The Manager is very fair. [Manager’s] door is always open for everyone if we have any concerns.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The management team had built and maintained strong relationships with healthcare professionals, working collaboratively with other services to ensure people received joined- up care. During the assessment, healthcare professionals spoke positively about the service and the quality of the working relationships they had developed. One professional said, “Mulberry Court always keep me informed and we work very well together. I trust them to take good care of people.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider demonstrated a commitment to learning and continuous development through effective governance systems.

Evidence showed lessons were learned from audits and general feedback. Action plans were implemented, clearly identifying how and when any gaps were addressed. Key issues were also shared and discussed during staff and handover meetings.

However, some staff feedback stated that additional training that had been requested had not always been arranged.