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Mulberry House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 3 December 2019

About the service

Mulberry House is a residential care home providing personal and nursing care for up to 72 people. The home is divided into two units. The Queen Mary unit provides nursing care for people living with healthcare needs such as stroke, heart disease diabetes and dementia. The Mulberry unit provides nursing care and support for people living with an acquired brain injury. This can be because of an accident or following a health-related condition, such as a stroke or Parkinson's disease. There were also some people, with a learning disability.

People’s experience of using this service and what we found

The quality assurance systems did not identify all the areas for improvements which we found. People’s records did not always reflect the care and support they needed and received. Improvements were needed to ensure risks to people in relation to some aspects of medicines management and risks related to their health and well-being were managed safely. We also asked the provider to make improvements to their recruitment procedures.

People’s care plans were not always followed, and others did not include enough information to demonstrate people’s needs were met. We made a recommendation about this.

People were supported by staff who treated them with kindness and compassion. Staff understood people’s needs, choices and knew what was important to each person. People were enabled to make their own decisions and choices about the care and support they received.

People were supported to take part in a variety of activities that they enjoyed and were meaningful. Complaints were responded to effectively. People’s communication needs were assessed and responded to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff received the training and support they needed to help them look after people effectively. They received training specific to meeting people’s individual assessed needs.

Nutritional assessments had been completed and identified the type of diet and support people needed. Staff were aware of people’s dietary needs. The registered manager had identified improvements were needed in relation to the food that people received and this was reflected in the mixed feedback we received.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was good (published 13 December 2018). Since this rating was awarded the provider has altered its legal entity. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected

The inspection was prompted in part due to concerns received about the care people received and staffing levels. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvement. Please see the safe, responsive and well-led sections of this full report.


We have identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to aspects of safety, people’s records and the quality assurance system at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 3 December 2019

The service was not always safe.

Details are in our safe findings below.



Updated 3 December 2019

The service was effective.

Details are in our effective findings below.



Updated 3 December 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 3 December 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 3 December 2019

The service was not always well-led.

Details are in our well-Led findings below.