Mulberry Court Care Home

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.