Mulberry Court

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We found 3 breaches of the legal regulations. People did not always have access to health professionals when needed. The provider did not make referrals for appropriate care and treatment at the right time, and recommendation for care and treatment by other professionals were not always carried out as directed. Staff did not always have the training and skills to coordinate care and support. People did not always have care plans to guide safe practice. Instructions from medical professionals were not always recorded in people's care plans or effectively communicated to staff. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the provider did not support this practice. Governance systems and audits were not effective in identifying or addressing areas for improvement. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

Instructions from medical professionals were not always recorded in people's care plans or communicated to staff. This meant people were not always receiving the most up to date support to meet their health needs. Relative told us: “There have been examples when a new member of staff has not recognised [my loved one was becoming distressed] and missed a chance to de-escalate a situation, then things have become volatile. Trained staff are more able to 'nip this in the bud’.”

Instructions from medical professionals were not always recorded in people's care plans or effectively communicated to staff. Comments from staff include: “From my experience of working at Mulberry Court the main area of worry is communication, although [electronic recording systems] are in place messages regularly don’t get to everyone; this can cause confusion and strain on the residents when staff are working in different ways.”

One healthcare professional told us: “The manager is not always up to date with what is going on with the residents. [Person] is fortunate that [they] have a close-knit family that are very involved with [their] care. It is generally [their] family that arrange and co-ordinate all [their] activities. Mulberry Court [staff] are not always proactive.” Another professional said: “The manager confirmed that the [choking] incident was recorded on [electronic recording system] but no medical advice was sought at the time of incident due to their 'naivety' and because [person] had been ok, they had not called for medical advice. This was also why there was a delay in contacting 111.”

People did not always have access to health professionals when needed. The provider did not make referrals for appropriate care and treatment at the right time, and recommendation for care and treatment by other professionals were not always carried out as directed . For example, 1 person’s diabetes risk assessment instructed staff to re- check blood sugar levels 3 times a day and contact 999 emergency services to seek medical advice if blood sugar were too high. Advice from medical professional was to check blood sugar levels before breakfast, evening meal and bed and record in the diary given. Staff failed to support person with checking their blood sugar levels or contact emergency services when their blood sugar levels were too high on several occasions. On the day of our inspection only 4 staff members had received training in how to support people with diabetes. That put people’s health and well-being was at risk of deterioration. The provider did not always take responsibility for ensuring that care and support is coordinated, leaving it to other agencies or relatives to manage. Information was not always shared with other services and when shared, it was not always adequate. Systems and processes such as how records and information should be shared were inconsistent. Staff did not always have training and skills to coordinate care and support.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Formal feedback from people had been sought however the results were not always used to make improvement. People were not always involved or consulted about the reviews of concerns, accidents, incidents, and adverse events and in planning to prevent similar incidents in the future. One person told us: “[The manager] has been the best manager out of all of them but things don't resolve even if you say something.” Relative commented: “There is a general acceptance of residents being ‘occupied’ by passive TV / screen watching. We do not feel that this is ‘care’ in the proper sense of the term” and “It seems very sad that [people] are left to their own devices which may mean sitting alone in a local cafe for hours. One would imagine that higher staffing ratios might mean opportunities for doing more with the residents and running group activities.” Seven out of eight relatives we spoke to, told us they were never asked for feedback. Comments included: “They have never actively sought our feedback about the provider.” Most relatives including people’s legal representatives, told us they are currently not involved in creating and reviewing people’s care plans. Comments include: “I haven't seen [my loved one] care plan. This is something they could do better. We never had a review, or I was never invited to the review”, “There has not been a face to face review since Covid. There is no other communication about [my loved one] care apart from two recent emails which came unexpectedly. [My loved one] used to have a key worker but it seems unclear who this is now.” and “I used to be involved, I used to come [over] for annual review. That stopped because of Covid and was never re-introduced. I would like that to come back.”

Staff told us they not always had relevant guidance and training to meet the needs of people they supported. Comments included : “Most key information in terms to each individual is in my experience gained from asking other staff members” and “When [a person] who undoubtedly has different complex needs to the majority of the other residents moved to Mulberry Court, as a team we only recently had autism training and have positive behavioural training, I believe this would have been beneficial prior to or soon after [person] moving in.”

We couldn't be fully assured that people's needs had been completely and holistically assessed. This was because the care records did not demonstrate this. For example, there was not always sufficient guidance in place to prevent risks as far as possible. Care and support plans were not always updated to provide staff direction as to how to support people in times of distress or in an emergency. People's needs were not always clearly reflected within their care plans. Information contained in people's care plans was not always clear and some information was contradictory . This placed people at risk of not having their needs met. Staff were working with minimal guidance and had not been supported to mitigate risks to people leaving them at risk of harm from aspects of their health and other conditions such as skin integrity, diabetes management and complex behaviours. For example, we saw records of 2 people that needed to be repositioned to relieve any pressure areas. Staff were not following the care and support plan in place for either service user exposing both to an increased risk of skin integrity breakdown. Staff had not received training in how to support people with maintaining skin integrity.

People were not always supported to have choice and control on their care. People told us they were not always offered choices and where appropriate were supported to make decisions . We revied provider’s satisfaction survey completed by 4 people. One person answered “No” to a question: “I am given choice and I live the life choose?” and another person commented: “Not always”. One person told us: “I can't make choices; they change my schedule and it's too much for me.” Relative commented: “We just feel that the TV is used too much to keep [people] ‘occupied’. [They] can be actively encouraged to do other things. We feel that they can be helped to make better decisions if the staff are trained to help them make good choices.”

Staff told us: “[People] get to choose how their day goes instead of the structure of eat at this time, wash at this time etc. They get up when they want, eat what and when they want”, “All individuals regardless of their level of care required are given choice, for example, all residents have the choice to decline assistance or request for another member of staff to support them. Before assisting with any care or support individuals are informed of what we intend on assisting them with, so they are in the position to decline or request otherwise” and “All [people] have ways in which they like things done and I always do my best to ensure I do it the way they like, to ensure their needs and wishes are met. They all have a choice relating to their care and when it comes to accessing the community.” Manager said: “There are conditions on the current authorised DoLS [for person]. It's something I haven't had a chance to do. That's specifically for the camera for the epilepsy at night, that's what I will be completing MCA for. The cameras are watched by waking night staff.”

People's rights were not always being fully respected and in accordance with the Mental Capacity Act. People were subject to unauthorised restrictions which invaded their right to privacy. For example, the provider did not have consent or capacity assessments in place for the use of image recording devices to monitor people in their bedrooms. Failing to document the use of continual surveillance was in people's best interests, put them at risk of their privacy and human rights not being protected. Consent was not always sought from people for individual decisions where appropriate. Where a person had restrictions in place such as a pressure mat which enabled staff to monitor the person's movements there had been on assessment of their capacity to consent to these, and no decisions made in their best interest. This meant people had restrictions in place which may not have been in their best interest. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Staff had received training in the MCA but not always followed principles of a best interests process in accordance with the MCA. The provider had made appropriate DoLS applications which had been authorised. Where people's DoLS authorisations contained conditions the provider must meet, these were not met. For example, 1 person's conditions required the provider to review and ensure that Mental Capacity and best interest paperwork is completed for all decisions pertaining to their care. Consent had not been sought lawfully to restrict their liberty with use of video monitor, lap belt, tilt and space chair and bed rails. This meant we were not assured this person's human rights in relation to their DoLS condition were being respected.