Mulberry House

Mulberry House is a residential care home providing personal care to 42 people. There were 16 people living there at the time of the inspection, although one person was in hospital. The home is spacious, and purpose built with a large garden, accommodating people across two floors with adapted facilities accessed by a lift.

People's experience of using this service and what we found

Since the last inspection, there have been various changes in the management structure as a new management team was recruited. At this inspection, there was a peripatetic manager who will remain in post until the new manager starts at the home in August 2022. The peripatetic manager will then become the area manager for two South West Buckland services. An interim home manager has been in place since February supported by a permanent deputy manager since March 2022. A new permanent home manager has been employed to start in August 2022.

The service had received extensive support from the local authority and quality assurance team during the unstable period since the last inspection. This support had enabled the service to improve along with the service management team changes. The service was beginning to embed the learning and new systems with positive results for people. The management team were now working with reduced local authority support using effective new systems.

Although the quality assurance governance systems were new and had not yet had time to fully embed to show sustainability, the current management team had worked hard. They had ensured the breaches found at the previous inspection had been addressed with a more stable and supported staff group. The provider had put more effective and robust governance systems in place to improve their oversight of the service and the work of the home and area management team.

We saw examples of how the positive improvements had impacted on ensuring people's needs were well met. There had been substantial investment to further promote good quality care at Mulberry House.

People were safe at the service. Staff had been trained to safeguard people from abuse and understood how to manage risks to people to keep them safe. Risks had been identified and addressed to ensure people remained safe. Staff had up to date information and actions taken were reflected in daily records. The service was still being supported by the local authority and the processes and training to keep people safe were still new, they needed to be embedded to ensure people continued to be safe in the service.

There were enough staff to support people, with staffing levels regularly reviewed and increased in relation to people’s dependency levels. The staff worked well as a team, including agency staff and were clear about what they needed to do. Recruitment checks had been undertaken to make sure staff were suitable to support people.

People chose to spend time in a choice of comfortable places, with staff supervision, if necessary.

The provider had adapted the premises to meet people's needs, for example creating a homely library area, a room for family and friends to meet in, attractive outside spaces and a large, welcoming communal area.

The premises were clean and tidy. Staff followed current hygiene practice to reduce the risk of infections with effective systems in place, including a designated laundry person and new housekeeping team. Visitors to the service were given information to help them reduce the risk of catching and spreading infection. Health and safety checks of the premises and equipment were carried out at regular intervals.

Peoples’ care and support needs were assessed prior to them using the service. There had been no new admissions since the last inspection. The peripatetic manager said care would be taken to ensure staff could meet peoples' needs before admissions in the future using a robust format.

Peoples’ care plans set out for staff in detail how their needs should be met; all care plans had been reviewed and were up to date. Staff understood peoples’ needs and how they should be supported with these. They received relevant training with ongoing competency checks to help them to do this.

Because staff had detailed and up to date information, they knew people’s care needs well. People received personalised support based on their assessed needs and preferences. A range of activities took place and people were supported to maintain their relationships and interests.

Staff were calm, kind and respectful of people. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported to stay healthy and well. Staff helped people eat and drink enough to meet their needs, to take their prescribed medicines and to manage their healthcare conditions promptly.

People, relatives and staff feedback indicated that since the previous inspection there had been great improvement in the way the service was run. Staff approached us throughout the inspection to tell us how much the service had changed for the better.

People and relatives were satisfied with the quality of care and support they received. The managers reviewed accidents, incidents and complaints to identify how the service could improve further and had taken action based on peoples' views.

People were encouraged to have their say about how the service could improve and there was good communication. Resident and relatives’ meetings had re-commenced alongside regular communication by telephone and email and a newsletter. The service worked with other agencies and healthcare professionals. We received positive feedback from visiting health professionals. The provider and management team had acted on their recommendations to improve the quality and safety of the service for people and had worked closely with the local authority and quality assurance team since the last inspection, thanking them for their support.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for the service was Inadequate, published on 7 February 2022. We identified breaches in relation to safe treatment and care, safeguarding, risk management, person centred care, need for consent, infection prevention and control, meeting nutrition and hydration needs, staff training and competency and good governance.

This service has been in Special Measures since February 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements. We also looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Mulberry House is a residential care home providing personal care for up to 42 people. At the time of the inspection there were 25 people living there. Five of those people were receiving intermediate care which meant they were planning to be discharged home following a short stay. The home is spacious, and purpose built with a large garden, accommodating people across two floors accessed by a lift, each of which has separate adapted facilities.

People's experience of using this service and what we found

Due to poor management of risk, people were at risk of harm. We found multiple examples of poor care and inadequate monitoring of risk in relation to malnutrition, dehydration, incontinence, falls, poor manual handling, infection control, choking and pressure care.

People and relatives expressed concern over the lack of stable management and staff team, a lack of communication and of not being listened to. One relative said, “We are there all the time, but [staff] rarely tell us things. My father tells us things.”

People were not adequately supported to eat and drink to ensure they were not at risk of choking. People did not receive appropriate diets or and were not supported to maintain good hydration and nutrition.

There was poor falls management with a lack of risk assessments or detail about how staff should minimise the risk of falls. Incidents and accidents were not always recorded, or appropriate actions taken to minimise the risk or identify and learn from trends and patterns.

People were not always able to access working call bells and those people who could not use a call bell due to their mental capacity had not been assessed or systems put in place to regularly check their wellbeing or to ensure their needs were being met.

There was poor pressure area care as there were no systems in place to ensure regular monitoring, recording or ensure actions were taken to minimise pressure skin damage. There was poor continence management resulting in soiled bedding and continence aids which further exacerbated people’s skin integrity.

People were at risk of poor moving and handling and the use of inappropriate equipment which put them at risk of harm.

People did not always have up to date care plans in place, so they were at risk of not having their care and support needs met by staff. Staff were not always knowledgeable about peoples’ needs or able to give person centred care because poor leadership did not enable them to have up to date information. Systems were not effective at sharing important information and was exacerbated by the high use of agency staff.

People were not protected from the risk of cross infection due to poor infection prevention and control practices relating to sharing of equipment, poor continence management and housekeeping.

People did not always receive their medicines as prescribed, including topical preparations, which put them at risk of ill health.

Staff leadership and deployment of tasks was poor and staff did not always know what they should be doing. However, people and relatives generally said that when people were supported staff were kind and caring. Comments included, “They treat [person’s name] with respect and kindness, every time I speak to staff, they speak of them. I have seen other residents being treated properly” and “Whenever I see [staff] around [person’s name], they are very kind and loving. The staff speak to you when you go through the building.”

Staff did not always have the necessary skills, training and supervision to support people effectively. Staff training and induction was not effectively managed. Supervisions did not routinely take place and staff competency checks were slow to be completed.

People were not always safeguarded from abuse because staff did not always identify safeguarding issues or record or follow safeguarding escalation processes to keep people safe.

There was poor oversight of the service and a lack of consistent and effective managers in post who had the time to make improvements. There was a lack of effective monitoring and systems in place to monitor the safety and quality of care.

People did not always have access to healthcare professionals in a timely way.

Staff were not always recruited in a safe way which put people at risk of poor care by staff who may not be suitable to support them effectively.

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 service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 December 2019). The service had a targeted inspection (published 15 September 2020) which was not rated. The service has deteriorated to inadequate. This is based on the findings at this inspection.

Why we inspected

We received concerns from the local authority identified during the ongoing provider quality support meetings in October and November 2021. These concerns were in relation to the lack of up to date care plans, training, particularly the lack of medicines training and competency and training in the electronic care planning system (PCS), high use of agency staff, management pressures resulting in a lack of improvement and governance oversight. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led. We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report.

Enforcement

We have identified eight breaches in relation to: the need for consent; safe care and treatment of people; person centred care; safeguarding people from abuse; meeting nutritional and hydration needs; staffing; premises and equipment; management oversight of the service, and a lack of good governance. We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to have updates and meet with the local authority through the whole home safeguarding process. We gave formal feedback to the provider regarding the urgent actions required following the first and second day of our inspection. We will request an action plan for the provider to complete so they understand what they will need to do to improve the standards of quality and safety. We will return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

We found the following examples of good practice.

All areas in the service were clean and there were appropriate procedures to ensure any infection control risks were minimised. No communal areas were currently being used as people were isolating in their own rooms.

Clear signage was displayed on entry and around the service detailing what PPE was required to protect people and if any person living in the service was at higher risk.

The registered manager was communicating with people, staff and family members regularly to make sure everyone had an understanding of procedures and precautions being taken, and how to keep people safe. The registered manager worked with the care staff team to ensure infection prevention and control measures were followed.

Cleaning and infection control policies and procedures had been updated in line with Covid-19 guidance to help protect people, visitors and staff from the risk of infection.

The registered manager kept up to date with appropriate training in infection control. The registered manager ensured all staff had completed training to ensure they knew how to keep people safe during the Covid-19 pandemic and outbreak in the service.

The registered manager ensured people living in the service, and staff, had access to additional support, including one-to-one meetings and contact by phone, to offer any emotional support needed.

During the summer months some families had met with their relatives in the garden. New arrangements were in place for families to meet in a safe area of the home during the winter months. This included being separated by a large screen. Staff helped people to stay in touch with family and friends through phone and video calls.

The staff were following up to date infection prevention and control guidance to help people to stay safe. The registered manager ensured staff and people who used the service understood why every measure was in place.

At the time of the inspection, people were all isolating in their own bedroom with staff support. Staff provided activities whilst maintaining people’s safety.

Further information is in the detailed findings below.

Mulberry House is a care home without nursing and is registered to provide accommodation and support for up to 42 people. People living at the service were mainly older people, some of whom were living with dementia or poor health. At the time of the inspection there were 26 people living at the service.

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about risk management, medicines management, staff competency including the Mental Capacity Act, care planning and overall governance. The overall rating for the service has not changed following this targeted inspection and remains Requires Improvement. The service was in a whole home safeguarding process relating to the above concerns almost continuously until July 2020, since the last inspection in September 2019.

Since the last inspection in September 2019 the service has gone through a period of management changes resulting in no registered manager for some months. This meant a new deputy manager had been in charge with some support from a new area manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. During this time the local authority and the quality and improvement team (QAIT) supported the service through the whole home safeguarding process.

We found no evidence during this inspection that people were at risk of harm as concerns had been addressed and new systems recently put in place. The new manager and deputy had made a lot of progress making improvements, identifying and recognising where these were needed and putting more robust processes in place.

The area manager was now applying to register with us as manager for Mulberry House and was based at the service full time. Priority had been given to ensuring staff had comprehensive training, improving inductions for new staff and management, manager level audits and care planning. A new Head of Care role had been created and they were very knowledgeable about people’s needs. However, it is noted that although the service had identified and recognised the improvements that needed to be made, the process was at an early stage and systems had not yet embedded, so we could not comment on sustainability. The provider overall governance still required improvements to ensure it was robust to support and oversee the new management at Mulberry House.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

People’s experience of using this service and what we found

People had person centred care plans that were now being reviewed meaningfully to ensure all the information the staff needed to meet people’s needs was included.

Risk assessments had previously not ensured people were safe but there were now risk assessments in place and ongoing audits to monitor their effectiveness. For example, in relation to falls, pressure care, behaviours which could be challenging and timely access to health care when people’s needs changed. Where risks had been identified there were care plans relating to these risks showing staff how to manage them.

Medicines were managed safely at this service as improvements had been made.

People were receiving care in a timely way by staff who were caring and knew people’s needs well. People said they were happy at the home. Staff spoke about how they felt that improvements were being made and they felt better supported by management. Staff comments included: “The new manager, deputy manager and Head of Care are approachable. I feel proud because we have good relationships with residents, we know the little things and they remember you” and “Systems have improved and seem to be working, we all work well now as a team”.

Enforcement

We did not look at all the previously identified breaches of regulations as this is a Targeted inspection. Therefore, these breaches must remain in place until we carry out another inspection. These breaches were regulations 9 (Person Centred care) and Regulation 11 (Need for Consent). We looked at Regulation 17 (Good Governance) and found this remained in breach as the very new systems were not yet embedded within the service to show sustainability and provider oversight was not robust.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 17 December 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mulberry House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. We will continue to work alongside the provider and the local authority to monitor progress. If we receive any concerning information we may inspect sooner.

Mulberry House is a care home without nursing and is registered to provide accommodation and support for up to 42 people. People living at the service were mainly older people, some of whom are living with dementia or poor health. At the time of the inspection there were 31 people living at the service.

People’s experience of using this service:

People and their relatives spoke highly of the service they received from Mulberry House.

However, we identified risks to people’s care that had not been clearly identified or met. Where risk assessments had been undertaken there was not always an associated plan to guide staff on how to reduce risks. Poor implementation of the change to a new care planning system had left people at risk of poor or unsafe care because documents were not ‘joined up’.

The provider organisation had not ensured the service was consistently well led. There had been multiple changes of management of the service, both locally and at regional level since the last inspection. A new manager had been in post for five weeks but had received no handover or induction on their appointment. This had left them unclear over what systems were in place, and ultimately left people at risk. This was a failure of organisational governance. We did not identify people had suffered harm as a result of this and immediately following the first day of the inspection a regional manager came to the service to support the manager. Together they had drawn up a clear action plan for improvements, which were being implemented.

Staff had worked hard to ensure people received personalised support which met their needs and preferences, however this had not always been recorded or updated in people’s care plans. People told us the service met their needs and relatives said the care given to people was of a high standard.

We found there was not a clear understanding of people’s rights in relation to any Deprivations of Liberty authorisations under the Mental Capacity Act 2005. No-one at the service was clear about who had an authorisation in place, or what conditions were attached. This meant people were at risk of not having their legal rights supported or respected.

The building had been updated and maintained to a high standard. We identified that because of the needs of some of the people living at the service there was a need for some additional adaptation to meet the needs of people living with dementia. The regional manager and manager had assessed the building by the time of the second day and told us they would be implementing the findings.

We identified some policies and procedures that were out of date. These were immediately rectified during the inspection.

People received their medicines as prescribed, and systems were in place to safeguard people from abuse. The service responded to any concerns or complaints about people’s wellbeing. Recruitment processes had been followed robustly, and enough staff were in place to meet people’s needs.

Staff spoke positively about people and their work at the service, which they said was a good place to work. Staff received the training and support they needed to carry out their role, and although we identified formal staff support systems had lapsed the manager had plans to re-instate these.

Rating at last inspection: This service was last inspected on 18 and 19 February 2019, when it was rated as good in all areas and as an overall rating. This had been the service’s first inspection since their registration.

Why we inspected:

The inspection was prompted in part due to concerns received about changes in the management structures, falls and safeguarding concerns. Since their last inspection there had been several management changes and the service had no registered manager in post for some months. A decision was made for us to inspect and examine those risks.

We decided to do a short, focussed inspection to assure ourselves they remained safe and well led. However, during the inspection we escalated this to a full comprehensive inspection as we identified concerns.

We have found evidence that the provider needs to make improvements. These amounted to three breaches of legislation, in relation to good governance, person centred care planning and understanding and implementation of the Mental Capacity Act 2005. Please see the key questions for Safe, Effective, Responsive and Well led in the full report.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

Follow up: We will continue to monitor the intelligence we receive about the service. If any concerning information is received, we may inspect sooner.

People’s experience of using this service:

Without exception all the people and relatives we spoke with praised the home. People felt safe and well cared for. People’s preferences were respected and staff were sensitive and attentive to people’s needs. Staff were seen to be kind, caring and friendly and it was clear staff knew people and their relatives well. The management of the home was described as “first class”.

There were sufficient numbers of staff employed to ensure people’s needs were met. Staff had time to sit and engage people in conversation and to support people’s involvement in social activities. Recruitment practices were safe and staff received the training they required for their role.

Risks to people’s health, safety and well-being were assessed and management plans were in place to ensure risks were mitigated as much as possible. Staff were aware of their responsibilities to safeguard people.

People’s care plans contained personalised information detailing how people wanted their care to be delivered. People and their relatives were involved in making decisions about their care.

People received their medicines safely and as prescribed. Medicine management practices were safe.

The home was spacious and well furnished. The environment was safe and equipment regularly serviced to ensure it remained in safe working order.

Consideration was given to providing a variety of leisure and social activities for people to enjoy.

Quality assurance systems were in place to assess, monitor and improve the quality and safety of the service provided.

Rating at last inspection: This is the first time this home has been inspected since it registered with CQC in July 2018.

Why we inspected: This inspection was scheduled based on the registration date of the home.

Follow up: We will continue to monitor intelligence we receive about the home until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.