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 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 68 (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 stated vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, this was not yet consistently embedded into everyday practice. For example, staff did not always encourage people to exercise control over day to day tasks, such as making their own drinks or participating in household activities. This showed the provider’s cultural expectations were still developing and not yet applied consistently across the service.

The provider had appointed a new quality assurance lead, strengthening oversight and improving accountability. Provider level monitoring had been tightened, leading to more consistent follow up of actions. Leaders, who had not always identified concerns independently at the last inspection, had taken a more hands on approach and worked alongside staff, which improved their oversight. People told us they saw leaders regularly, and staff said leaders were accessible. The service had also begun working more closely with other services in the organisation to share learning and good practice.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. All staff we spoke to told us they felt comfortable and confident they could raise concerns if they needed to.

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. Staff told us they were well supported. Staff received equality and diversity training.

During this inspection, we found the provider had strengthened their governance arrangements. Roles and responsibilities were clearer, and leaders demonstrated an improved understanding of their accountability. Systems to monitor risk, performance and outcomes had begun to operate more consistently, and where information needed to be shared with partners, this was done appropriately. However, some changes were still developing and were not yet fully embedded across the service. We found variability in how consistently new systems were applied, and some actions identified by the provider remained outstanding. This meant the provider had not yet achieved fully effective and sustainable governance.
The provider had an action plan in place and acknowledged the further work required. We will check for improvement during our next inspection.
 

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. For example, the provider shared information with the local authority and CQC where this was required.

We found the provider had improved on their systems that promoted on their continuous learning. This had led to improvement at Mulberry House. Where actions were identified via the providers governance systems, they produced action plans which were progressed and regularly reviewed. Additionally, the service recently recruited a quality lead to and support the management team to identify and action any improvements required. This promoted continuous improvement.