Mulberry Care Limited

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

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 Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 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.

People and staff were encouraged and supported to raise concerns, they felt confident they would be treated with compassion and understanding.

Staff told us they were updated about incidents and changes; one staff member told us. “The Manager will discuss lessons learnt with us in team meetings” Records also evidenced Incidents and accidents were discussed in handovers and meetings. This meant that the service was able to identify lessons learned and implement corrective actions to prevent the risk of further safety events.

The registered manager understood their responsibilities regarding legal regulations by contacting relatives or representatives if an incident or accident occurred. This meant that people and their relatives were kept informed of safety events and any mitigating strategies implemented as a result.

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.

The staff worked with several professionals to ensure continuity of care within the home. People had regular visits from the GP and staff made appropriate referrals to healthcare professionals as required. People had hospital passports to support moving between health services and home. This meant communication was effective and there was a safe pathway between accessing services.

Relatives told us they were informed when their family member required support or treatment from other agencies, one relative told us, “As a family we are happy with [their] care- the home keep us up to date about [them]”.

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. The provider shared concerns quickly and appropriately.

People told us they felt safe living at the service and were confident staff would support them when needed. One person told us, “Yes, I feel safe- I know there is a thorough lock up at night- we have a night staff, they are all men but that is alright- they are all very good, very kind and very thorough”.

Mental capacity assessments were in place to safeguard people’s rights in relation to decisions about any risks.

Staff had received safeguarding training and regular refresher sessions to keep their knowledge up to date. Staff were able to clearly describe signs of potential abuse and the actions they would take. A person’s relative told us “Yes, [person] is absolutely 100% safe.”

Records confirmed the provider was proactive in raising safeguarding concerns with the local authority, however, the provider had not always notified the CQC in line with regulations. We gave feedback to the provider, and they acted to remedy this.

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.

A risk management system was in place and risk assessments were held in care plans. These provided staff with guidance on how to support people to keep themselves safe.

Risk assessments were clear, regularly reviewed, and included severity scoring to support staff in understanding the level of risks. When people were identified as being at risk of pressure ulcers or falls, appropriate measures were in place, such as equipment and regular reviews with healthcare professionals. This helped to minimise the risk of avoidable harm.

Another person was at risk of choking. The service worked with a speech and language therapy service (SALT) to guide staff to support them with eating and drinking. We observed staff followed specialist guidance, such as providing the correct food textures and levels of supervision, which reduced the risk of choking and helped keep the person safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a safe, clean and well-maintained environment that met their needs. Systems were in place to monitor the premises and identify concerns such as faulty equipment or trip hazards. Daily and weekly checks of the environment were completed, including water temperatures, fire safety checks and kitchen equipment. Staff told us repairs were reported and addressed promptly.

The home was designed to be dementia friendly, which meant people living with dementia were able to navigate the environment more easily, maintain their independence and feel safe and comfortable.

Equipment used to support people was appropriate for their needs, regularly serviced and stored safely. The provider had an up-to-date emergency plan to guide staff in the event of an incident. Personal emergency evacuation plans (PEEPs) were in place for each person and clearly set out the support they would need to evacuate safely in the event of a fire or emergency. This helped ensure people could be supported quickly and appropriately.

The fire risk assessment and outstanding actions had been resolved. During the inspection, we identified three fire doors with gaps at the bottom, which would have provided ineffective protection in the event of a fire. The provider acted promptly, seeking advice from the local fire service and taking action to address this.

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.

There were enough staff to meet people’s needs safely. Staffing levels were based on people’s individual needs and staff told us they had time to provide care and support in a person-centred way.

One relative told us, “Yes, I regard [person] as being safe. The staff always seem to be about and to be there for [them]. When I visit, you always see staff sitting with residents, people are never unattended, even when others are shouting or demanding attention.” Another said, “All the staff, they all feel professional and kind. It is always well staffed, there are always plenty of staff around. Everyone always stops and says ‘hello’, speak and always speak to [person] clearly and kindly- I feel that [they are] safe and well cared for.”

Recruitment processes were managed safely. Pre-employment checks were completed, including Disclosure and Barring Service (DBS) checks, references and proof of identity, to help ensure staff were suitable to work with vulnerable people.

Staff had the right skills and experience to carry out their roles. They completed an induction and ongoing training relevant to people’s needs, such as moving and handling and safeguarding. Staff told us they felt confident in their roles.

There were systems in place to support staff through regular supervision and appraisal. Staff said they felt supported by the management team and could raise concerns if needed. The provider monitored staff performance and competency to help ensure safe and effective care was delivered. This meant staff were appropriately supported, accountable and competent in their roles, which promoted a positive culture and helped ensure people received safe, high-quality care.

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.

Staff used personal protective equipment (PPE) appropriately during personal care and understood how this helped reduce the risk of infection. Infection prevention and control policies were in place and up to date.

Cleaning schedules were in place and followed. People’s bedrooms, bathrooms and communal areas were clean and well maintained, with regular checks completed to ensure good standards were sustained.

This meant people were protected from the risk of infection and staff understood how to maintain a safe and hygienic environment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medication Administration Records (MARs) evidenced people received their medicines safely and as prescribed. We observed staff wearing ‘do not disturb’ tabards when administering medicines to reduce distractions. We saw staff explain medicines to people upon administration, gain consent and support them in a respectful way.

The provider used an electronic medicines system to support safe practice, improve efficiency and provide clear audit trails. People’s medicines were regularly reviewed by the GP. It was clearly documented where a medication had changed and this was communicated by the Register Manager to the staff team.

There was a medicines policy in place, with clear processes to report and investigate errors. Regular audits were completed to identify learning and improvements. Staff received medicines training and had their competency assessed before administering medicines.

Medicines were stored safely and securely. Medicines trolleys and cupboards were locked when not in use, and access was restricted to authorised staff. Temperatures for medicine storage areas, including fridges, were monitored and recorded to ensure medicines remained safe to use.