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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.
The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the service was no longer in breach of this regulation.
 

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment we found the provider did not learn lessons to identify and embed good practice. At this assessment we found improvements had been made. 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. The provider reviewed incidents, accidents and near misses.

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. We found improvements had been made since our last inspection. Care plans had now been fully transitioned over to the provider’s digital care system and were regularly reviewed and updated as required. This meant staff now had access to information that was current and up to date. Where other professional involvement was needed, this was documented and promptly sought.

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. Where safeguarding concerns were identified, the provider shared concerns quickly and appropriately.

During our last assessment we found care planning and risk assessment had not been completed appropriately and identified concerns. Now, 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. People had clearer care plans in that identified risks people could experience and how to manage these. People told us they felt safe, one person said, “I feel safe and I like it here.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Since our last inspection, several improvements had been made to the environment. For example, fire doors had been fitted with automatic closure device and fully replaced where required. Shower units had been replaced with speciality showers to prevent the risk of scalding. Broken furniture had been fixed or replaced entirely.

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. Since our last inspection, all staff had received refresher training in a number of areas. Competency assessments had been completed in key areas, for example, moving and handling. There was an ongoing plan to assess competency in a range of topics on and ongoing basis.

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. During our last assessment we found a number of areas in the service were unclean or had a strong malodour. Now, we found the service was clean and free of malodour. Many areas had recently been decorated, and people had chosen their own room colours where able to.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found medicines were stored and administered safely. Records were clear and up to date. When required medicine protocols and medicines risk assessments were in place, however, would benefit from being more person centred as these contained only generic guidance for staff and did not always reflect the individual needs of the person. The provider acknowledged our findings and told us they would address this as part of their ongoing action plan. We will check for improvements at our next assessment.