Mulberry Court Care Home

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 Good. At this assessment the rating has changed to Requires Improvement. This meant that the governance processes did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders set a clear vision and positive culture. Vision and values were in place and referred to in team meetings and supervisions.

Managers were very clear on the standards they expected, and team meeting minutes showed they set out where standards needed to improve and how they expected staff to act which included challenging poor practice where they saw it. Staff were clear on what was expected of them and told us they would raise any concerns with management if required.

Leaders were skilled, compassionate, and inclusive. Leaders monitored the service closely and took action to improve the service though they had not identified and addressed the issues we found during this assessment. Team meetings showed clear communication between the registered manager and staff.

A relative said, “I can raise any issue with the manager. She has made me so comfortable. I can get it off my chest and I’m assured that she will sort it. I raised an issue with the manager, and she spoke to the staff member and there have been no issues since.”

Leadership was described as strong, supportive and visible. A staff member said, “[The registered manager] is a supportive manager and the team is also supportive. I can go to her with any problems.” Another staff member said, “Management listen to my views, and I feel treated well by management.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People felt able to speak up and raise concerns. Staff were confident raising issues with management and felt they would be acted upon. Staff understood the organisation’s whistleblowing procedures and were clear about how to escalate concerns if they felt people were at risk. A ‘raising concerns, speaking up and whistleblowing’ policy was in place. This was also highlighted in the staff code of conduct.

A staff member commented, “I have had concerns about agency staff in the past and highlighted them to the manager and actions were taken.” Team meeting notes showed evidence of staff being given opportunity to speak up and drive improvement.

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. The workforce was treated fairly and inclusively.

Staff felt they were treated fairly and not discriminated against. They did not feel pressured to accept additional shifts.

A culture day had been held where staff were asked to wear any traditional clothing, prepare a speech about their home country and play music or dance. The registered manager told us that it had helped to bring staff closer and to respect each other’s cultures and values.

Governance and management systems were not fully effective. Governance processes were in place, and an audit schedule was followed to monitor the service. This included daily walkarounds, a range of team meetings and a range of other checks to monitor the quality of care being provided. An emergency continuity plan was in place. However, these processes had not identified and resolved the issues we found at this assessment. These 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, resulting in reliance on external prompting rather than proactive management.

A range of policies were in place regarding information governance and the use of information. The provider had achieved an ‘exceeded’ rating for the Data Security and Protection Toolkit standards and achieved standards for cyber essentials plus, a data security accreditation.

The CQC rating was displayed, and notifications were made to the CQC as required. A registered manager was in place.

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.

The service worked in partnership with others for people’s benefit. Processes were in place to ensure suitable referrals to other community partners and agencies and had been appropriately followed by staff.

Professionals were positive regarding their relationship with the service. A professional commented, “They have always considered taking residents whom many care homes would not accept due to their challenging behaviours and needs. They have always tried to do their best and always have their resident’s best interest at the heart of what they do.” Another professional commented, “We do not have any concerns with the service, and we work well collaboratively to keep complex patients out of hospital.”

The service was committed to continuous learning and improvement. Staff completed a range of audits and areas for improvement were discussed at team meetings and through staff supervisions and appraisals. However, these processes had not identified and resolved the issues we found at this assessment.

The service used technology to monitor people’s bedrooms when people were sleeping to minimise the amount of safety checks required to improve the quality of sleep. Team meeting minutes noted that this had been effective, but that continued work was required to ensure that it remained so.