Mulberry Court Care Home

Updated 22 January 2026

Date of assessment: 17 February 2026 to 2 March 2026.

The service is a nursing home providing personal care and support to younger and older adults living with physical disabilities and/or dementia. At the time of the assessment the service supported 40 people.

The last assessment of Mulberry Court Care Home was published 6 March 2019; the overall rating was Good. At this assessment the overall rating for Mulberry Court Care Home is Requires Improvement. This is based upon the findings at this assessment.

This assessment was carried out due to the length of time since the last rating and in response to a prevention of future death report issued by the Coroner following an inquest.

Governance systems were not sufficiently effective to ensure the quality and safety of the service were consistently monitored and improved. Although a range of audits, checks and monitoring processes were in place, these did not reliably identify or address the issues found during this assessment. This included weaknesses in infection prevention and control oversight, where audits and cleaning schedules did not identify environmental cleanliness concerns, and shortcomings in environmental safety and adaptation for people living with dementia. Systems for monitoring Deprivation of Liberty Safeguards (DoLS) authorisations were not robust, which resulted in reliance on external prompting rather than proactive management. These issues demonstrated that governance arrangements were not consistently effective to identify risks and drive timely improvement resulting in a breach of Regulation 17 (Good Governance). We have asked the provider for an action plan in response to the concerns found at this assessment.

Almost all relatives felt their family members were safe. Processes for monitoring DoLS authorisations could be improved. Staff understood safeguarding and risk management, and medicines were handled safely. Infection control was not fully effective, and the premises was not fully adapted to meet the needs of the people living there.

Care was based on best practice, with regular assessments and monitoring. People were supported with nutrition and hydration, and staff worked well with healthcare partners. Dental care had been difficult to arrange but was now starting to be provided in the home. Consent was respected.

Staff were caring but people’s dignity was not always respected. Independence was encouraged but people were not always fully supported to make choices. Activities were available but limited at times. Staff wellbeing was promoted.

Care was person-centred and there was continuity of care. There was evidence of some involvement of people and their relatives in their care, but this could be further improved. End of life care plans were in place but required further development to reflect people’s wishes in this area.

Systems and processes to assess, monitor and mitigate the health, safety and quality of the service were not fully effective. Leadership promoted a positive culture and staff felt able to speak up. A registered manager was in place, and staff and relatives commented positively on their leadership and approachability.

Updated 22 January 2026

We sought feedback from some people who used services and relatives of other people who used services who were unable to speak with us.

People and their relatives were mostly positive about their experiences of care. Many described staff as kind and approachable, and said continuity of staff helped people feel settled and reassured. A relative said, “It’s the same staff on [family member’s] floor too so you get the continuity and they rarely seem to use agency.” Several relatives told us that their family members appeared calmer and safer than in previous services and spoke positively about cleanliness and food. One relative commented, “This place is streets ahead from where [family member] was. It’s clean, very friendly staff and the food looks good.” Relatives also described positive experiences of support during hospital admissions and said staff knew people well.

One relative raised concern about aspects of care for their family member, including staffing levels at the weekends, communication difficulties and whether care always reflected their changing needs. These views were not reflected by other relatives we spoke with; however, we reviewed these concerns as part of our assessment.

People using the service experienced care that was not always consistent and did not reliably promote dignity and choice. People received support with nutrition and hydration, and their health needs were monitored with involvement from healthcare professionals when required. However, people were not consistently supported to make informed choices, particularly at mealtimes, as meals were not routinely explained and visual aids were not used to support understanding. Opportunities for meaningful activity were variable, and some people, especially those who spent long periods in their rooms, experienced limited engagement. Staff usually responded to people’s needs, but there were occasions where people who became distressed were not supported in a way that reduced anxiety or upheld their dignity.