Mulberry House

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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service continued to be in breach of legal regulations in relation to governance at the service.

This service scored 36 (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 clear shared vision, strategy and culture based on equity and engagement. People did not always receive care in line with the current best practice guidance of right support, right care, and right culture. For example, people did not always experience good access to local communities, which most people take for granted and a lack of prompt action to ensure the physical environment was always clean and well maintained, was not reflective of a caring culture for people to live in. This increased the risk that the culture in the service did not always promote people enjoying a full life and having all their needs and preferences met.

The service did not demonstrate they had capable leadership with the right skills and knowledge. We identified new and continued breaches of the legal regulations and concerns in areas such as safe care, person-centred care and governance. Leaders had not independently identified and acted in relation to these concerns prior to our assessment.

Following our last inspection, leaders developed an action plan which outlined the steps they would take to meet the regulations. At this inspection we found these actions had not been effective in meeting the regulations.

Most residents at Mulberry House had lived there for many years. While they told us they would feel comfortable voicing any concerns, the provider had not effectively communicated their rights, or the expectations of the services offered. For example, relatives told us they were waiting for social services to provide additional funding to enable their loved ones to have furniture replaced. This is not the responsibility of social services and should be undertaken by the provider. This lack of clarity limited people’s understanding of the issues they could raise. For example, in relation to the environment and activities. Despite our findings, staff told us they felt comfortable to speak up and would go to the manager if they had any concerns.

Staff we spoke with felt well supported by managers. Staff told us they felt they were treated equitably and fairly.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At our last inspection we found systems and processes were either not in place or not effective to monitor quality and ensure the building, environment, and facilities were clean and safe for people to use. At this inspection, improvements had not been made, and we continued to find concerns with the governance systems in the service.

The provider had not identified concerns related to the managing risks, training, the safety of the environment, care planning and ensuring people always received person-centred care. We found people were at risk of being exposed to harm during this inspection. The provider had some audits in place; however they failed to identify the concerns found during this inspection.

The provider did understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

People were not always supported in being part of their local communities. Care records did not reflect people or their relative’s involvement. Improvements were needed in systems to deliver care collaboratively based on people's day-to-day experiences.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The provider has not achieved a good rating at Mulberry House for the last 4 inspections. There are similar themes of concern found during this inspection that we have identified previously. This meant we could not be assured leaders had a good understanding of how to make and sustain improvements at this service. This placed people at continued risk of not receiving care that met their needs and preferences.