Mulberry Court

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 – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 66 (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.

The service had a system in place for reporting, reviewing and analysing incidents and accidents. The manager reviewed accidents and incidents across the service regularly, to identify trends and themes. Staff recorded and reported any safety concerns that occurred and told us any lessons learned were shared with them in staff meetings to prevent recurrence.

People’s care plans and risk assessments were updated following incidents if required.

Referrals had been made as necessary, including notifying the Care Quality Commission (CQC) of specific events as required.

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.

Staff obtained information from the person, their family, and health and social care professionals involved in their care to support with transitions. This gave staff clear information about how to support the person and enabled a smooth and safe transition to the service. Potential new people visited the service to see if it would meet their needs, and to meet other people living at Mulberry Court.

Information about the person, such as people who were important to them and their health conditions was recorded, along with what support they needed with personal care, mobility, nutrition. Other areas included details of people’s religious beliefs, interests and social history.

Staff supported people to attend medical appointments and shared information when they were admitted to hospital. This helped ensure the person received care that was in line with their wishes and preferences.

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.

Everyone we spoke with told us they, or their loved ones felt safe, and that staff knew people well. A relative said, “Mulberry Court and the other residents are his home and family so [loved one] does feel happy and safe there”.

Staff were aware of their responsibilities to safeguard people from avoidable harm. They completed safeguarding adults and children training and were aware of how to report and record any concerns identified. A safeguarding adults’ and children’ policy was in place and regularly reviewed. The management team worked with the local authority safeguarding team to learn from and implement recommendations following any concerns raised.

The provider had a robust process in place to ensure concerns were reported to the local authority without delay. The manager had oversight of all concerns raised, this allowed them to identify patterns and monitor outcomes. This supported continuous improvement in safeguarding practices.

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.

Risks were assessed and measures taken to ensure people were safely cared for at Mulberry Court. Risk assessments were reviewed each month and updated as needed. People’s risk management plans included communication profiles that informed staff how people communicated so staff could respond quickly to people’s immediate needs, this included how people expressed if they were in pain.

People had positive behaviour support plans in place which instructed staff about how to support people safely. Relatives believed staff knew their family members well and understood risks.

People had personal emergency evacuation plans (PEEPs) in place, which were easy to locate. PEEPs provide staff and emergency service personnel with critical information on the evacuation needs of each person in the event of an emergency.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At the time of our assessment, we identified four environmental safety concerns that put people at risk. The front door was not secure to bungalow one. The staff had not identified the aid call system was switched off, this meant people who needed staff attention may not have received support as they needed. Risk assessments had not been completed to identify wardrobes that had not been attached securely to walls were a potential cause of harm if they tipped over.

There was a large crack in the window of bungalow two kitchen.The crack in the window had been temporarily made safe and the provider confirmed shortly after our inspection that the replacement glass had been fitted. The front door, aid call system and wardrobes were addressed promptly; However, the wardrobes and aid call system had not been identified as a risk during 'walk arounds' or audits. The manager confirmed during our assessment the areas of concern we raised had been actioned.

A maintenance log was in place and staff told us requests were usually promptly addressed.

The provider made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. There wasn’t always enough staff available to meet people’s individual needs.

People and their relatives felt care and support was delivered safely. One relative told us their loved one, "Does feel happy and safe at Mulberry Court." However, we received feedback regarding staffing levels and high turnover of staff, including the management team. One relative said, "We frequently get the impression there are not enough staff." Staff told us, “I think there is enough staff, but somethings don't get done like the laundry.”The manager acknowledged this feedback and reported that staffing levels were considered appropriate, but confirmed that staffing will continue to be monitored and reviewed to ensure they remain responsive to people’s needs.

Staff had access to training and there was evidence of observation and competency checks. Staff told us they received regular supervisions; records we saw showed this.One relative said about the staff, “Yes I do feel they are well trained.” Staff told us they were satisfied with the training they received and were encouraged to obtain further qualifications if they wished, to enable progression to more senior roles.

Recruitment procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer.The information helps employers make safer recruitment decisions.

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.

We observed the service to be clean. Staff told us they were responsible for cleaning the home and people were involved.

Infection prevention and control measures were in place. Staff had access to and wore appropriate personal protective equipment (PPE).

We observed staff using handwashing facilities and using PPE correctly.

Everyone we received feedback from felt the service was clean and ‘homely’.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found areas of medicines processes that needed improvement, such as Paracetamol was not always being given with a minimum 4 hour gap. One person was prescribed a blood thinning medicine, however no risk assessment had been completed about the increased risk of bleeding.The provider confirmed shortly after the inspection that a medication risk assessment for blood thinner medication had been added to the online care planning system for all staff to access.

Medicine audits had not identified these shortfalls. These were raised with the manager and addressed immediately. Shortly after our inspection, the provider confirmed action would be takento further strengthen monitoring and governance in this area.

The management team were working with people’s GP to review prescribing practices and where possible reduce the prescribing of psychotropic medicines in line with STOMP. STOMP is a national NHS England program to Stop The Over-medication of People with a learning disability, autism, or both, with psychotropic medicines.

Staff had regular training, and their practice checked to ensure they administered medicines safely. Any errors or incidents were investigated and reported, so that systems could be put in place to prevent them recurring. Feedback from relatives suggested people received their medicines safely when they needed them.