Mulberry House

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment. 

This service scored 38 (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 did not have a proactive and positive culture of safety. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice. For example, we found 2 fire risk assessments had been completed in the past 4 years, both identified actions to improve safety. The provider had not acted upon these assessments and did not have a plan in place to address these areas until prompted to do so by the commission. The commission had also raised concerns during previous inspections in relation to fire related risks. This placed people at increased risk of harm. The provider did not have a clear improvement plan in place to drive improvements.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. Health risks to people were not always well managed, and care plans did not always reflect people’s needs. Care plans did not contain current, up to date information, for example, one person required equipment to mobilise and transfer, however, care plans had not been updated to reflect this change in care need. This meant if people were seen by other services, they would not have the most current information to meet people’s needs and keep them safe.

People were not always protected from the risk of abuse. Whilst people told us they felt safe in the service and staff understood their responsibilities in relation to safeguarding and knew how and who to report any concerns to. We found examples where the provider had neglected their duties. For example, in seeking medical support and ensuring people lived in a safe environment. Despite our findings, people told us they felt safe. One person said, “I feel safe. I feel safe in my room and come down when I want to see other people or staff.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last inspection we found sufficient care planning and risk assessment had not been carried out. During this inspection we found not enough improvement had been made and we continued to find concerns in this area.

For example, one person was at risk of infection impacting their ability to have elective treatment to promote their hearing; care plans had not been updated, and risk assessments were not in place to guide staff on how to support the person to manage this risk. Where there were environmental risks, for example in relation to infection prevention and control and fire related risks, the provider had not taken to mitigate these risks.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care.

We identified fire doors were held open with objects such as laundry baskets and boxes, this prevented them from automatically closing in the event of fire, we also noted all fire doors in the service were defective, which had also been highlighted in the past 2 fire risk assessments, and all showers in the service could reach high temperatures which presented a scalding risk. As a result of our findings the provider acted: they replaced fire doors in the building and replaced the showers presenting a scalding risk. One person told us, “My room is OK. I do not like the TV being on top of my armchair”

The provider did not always make sure there were enough qualified, skilled and experienced staff. Where people needed equipment to support their mobility and transfers, we found staff had not received appropriate training in how to use the equipment nor had they been assessed as competent to enable them to use this equipment safely. This placed people and staff at risk of injury. However, we found staff were recruited safely and staff told us they received regular supervision and attended regular staff meetings.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

At our last inspection we found the service was not always clean and there was one room which had a strong smell of urine, there was no plan in place to address these concerns. At this inspection we found improvements had not been made.

We found multiple areas of the service were unclean. For example, en-suite bathrooms had evidence of mould and rusty handrails. Where surfaces had become damaged, for example with wooden furniture, they could not be effectively cleaned.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We identified shortfalls in the providers systems to ensure staff had received competency assessments and records were accessible to staff. For example, staff told us they had received competency assessments by a member of the management team, however when we spoke to the management team member, they were unable to provide these records and were unable to locate a copy of the document. Whilst we were sent a template of the document after our site visit, we could not be assured around the management of staff training in relation to medicines. We found one person had their medicines records stored in their bedroom, these were not current. We raised this with the management team who promptly replaced them with updated records. We also found some medicines had expired, placing people at risk of receiving medicines that may no longer be effective.