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Mulberry House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 27 June 2019

About the service:

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

Inspection areas


Requires improvement

Updated 27 June 2019

The service was not always safe

Details are in our Safe findings below.


Requires improvement

Updated 27 June 2019

The service was not always effective

Details are in our Effective findings below.


Requires improvement

Updated 27 June 2019

The service was not always caring

Details are in our Caring findings below.


Requires improvement

Updated 27 June 2019

The service was not always responsive

Details are in our Responsive findings below.


Requires improvement

Updated 27 June 2019

The service was not always well-led

Details are in our Well-Led findings below.