Mulberry Court

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The manager had worked hard to improve the culture in the service. This was achieved by promoting a shared vision across the staff team and leading with openness and honesty. Staff told us they shared the manager’s passion to continually improve how people received their support.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Feedback from people and their relatives was mixed about being able to contact the manager, with comments such as, “We do not know the new manager apart from correspondence around [name] care costs. There is regular turnover of staff.” However, overall people and their relatives were confident in raising concerns or issues they may have.

The manager understood their responsibilities under the duty of candour and notification to CQC and other agencies.

Staff told us the manager was supportive and approachable; however they would value some stability in the management structure.

Throughout our inspection, the management team was open about the improvements that still needed to be made and was motivated to learn and improve the service.

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

Relatives and staff told us they were confident any concerns raised would be taken seriously and dealt with effectively.

The provider had policies and procedures in place which guided people how to make a complaint. These documents were available in a range of formats so everyone could access them. Records showed complaints were dealt in line with the policy and compliments were shared with the staff team.

Policies and procedures were also in place to guide staff about speaking out and raising issues or concerns and staff told us they were aware of those policies. Staff told us they felt listened to when raising concerns to the service’s management team.

The provider sought formal feedback from staff about the service it provides. This was used to make improvements, such as; ‘You said, we did’.

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.

Staff told us they felt valued and respected by both the provider and the manager, they felt supported to give feedback and were treated equally, free from bullying or harassment.

The provider had a policy in place to ensure staff were treated fairly and had equal opportunities to learn and develop their roles within the organisation. There were fair recruitment processes in place, which helped to protect the rights of staff under the Equality Act. We observed staff working together and communicating effectively with each other during our visits.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider continued not to operate good governance systems. This was a continued breach of the regulations.

Systems and processes to monitor the quality and safety of the service were not robust and did not identify the shortfalls we found during our assessment. For example, medicines audits did not identify or address the concerns with medicines found during our assessment. Environmental risks had not been identified. The provider made some improvements in compliance with The Mental Capacity Act. There was lack of consistency in how the service was managed. However, following our feedback the management team took immediate action in these areas. Shortly after our inspection the provider told us the daily manager’s walkaround has since been strengthened to include more detailed environmental check.s

People and relatives told us the service would benefit from a permanent manager and deputy manager. Comments received included, “There hasn't been much leadership from the various managers that have come through.” The current interim manager told us they would apply for dual registration, and a deputy manager had been appointed.

Policies and procedures underpinned working practices, and this was supported by training and ongoing monitoring.

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.

We found referrals were made to healthcare professionals, such as mental health services appropriately. The advice given had been updated in people’s care records for staff to follow. Collaboration with external stakeholders included healthcare professionals, local authority social work and safeguarding teams.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The manager and provider had not always identified necessary improvements. However, they were responsive both during and after this assessment and acknowledged where improvements were needed. A member of staff told us that any learning from accidents or incidents are shared with staff, they said, “I think the service is trying very hard to improve.”

There were still areas that needed improvement, such as the environment, medicines and working in line with the mental capacity act. Although these were raised with the manager and addressed immediately, overall governance and quality assurance systems had not demonstrated sustained improvement. At this assessment, the inspection team had identified that the provider failed to fully embed and sustain their action plan to ensure they met the regulations in all areas of improvement previously identified. We found the provider remained in breach of the regulations relating to safe care and treatment and management and governance.

There had been a high turnover of management staff at the service, however the interim manager was registered for dual registration shortly after this inspection. A deputy manager had recently been recruited, and the service was recruiting to a senior staff vacancy.