Mulberry House

Mulberry House is a residential care home providing personal and nursing care to 67 people who are living with a range of health needs, for example, diabetes and heart disease. The service also supports people living with an acquired brain injury, this can be due to an accident or health related such as a stroke. There were people with a learning disability, who were living with other health related conditions or an acquired brain injury, which was their prime reason for care. The home can support up to 72 people.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic. The manager was aware of the principles of RSRCRC. At the time of the inspection people living with learning disabilities and/or autism required nursing care.

Since the last inspection improvements had been made. There was a clear management structure that had established quality systems that supported effective leadership and oversight of the service. Audits and quality monitoring identified areas for improvement and development. For example, accidents and incidents were reviewed to identify any trends.

There had been a focus on improvement and service development for the benefit of people. For example, the environment had been subject to an intensive refurbishment and redecoration programme.

Infection control practice had improved, equipment had been replaced and staff were fully supported to follow government guidelines on infection control at all times.

Medicines were ordered, stored and administered safely. People received their medicines as prescribed and practice to support the effective and safe use of anticipatory medicines had been reviewed and were in place.

Care documentation had been reviewed and now confirmed why people stayed in bed and if they were able to use their call bells. Risk assessments clarified what was measures were in place if people were not able to use their call bells.

People received safe care and support by staff trained to recognise signs of abuse or risk and understood what to do to support people safely. Risk assessments were used to identify individual risk and to minimise risks as far as possible. There were enough suitably trained and experienced staff to meet people's needs including the individual 1 to 1 time required. Safe recruitment practices had been followed before staff started working at the service.

People received individual time with staff to engage in activity and entertainment that met their individual needs, this included individual trips out. Complaints were recorded and responded to effectively.

People's communication needs were assessed, and professional advice was used to enable the most productive communication models were used. End of life care was planned and involved additional health care professionals when needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There was a stable management structure and staff felt well supported and valued. There was a positive culture and team spirit amongst all the staff.

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 21 July 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation 17.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Mulberry House is a residential care home providing personal and nursing care to 59 people who are living with a range of health needs, for example, diabetes and heart disease. The home also supports people living with an acquired brain injury, this can be due to an accident or health related such as a stroke. There were people with a learning disability, some of whom were also living with other health related conditions or an acquired brain injury. The home can support up to 72 people.

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

Since the last inspection some improvements had been made but further time was needed to fully embed these changes into day to day practice.

There had been changes made to record keeping, this included a new computerised care planning system. However, further improvements were required to ensure that records fully reflected people’s needs and contained all the information staff may need to support a person when they displayed behaviours that may challenge. Improvements were needed to ensure all incidents were appropriately recorded to ensure the provider had full oversight.

Quality assurance systems identified some areas for improvement and action plans were in place for these but further time was needed for these areas to be fully addressed. Other areas had not been identified and this is an area that needs to be improved. Improvements were needed to ensure appropriate infection control measures were in place.

People their relatives and health and social care professionals were not routinely asked for their feedback about the service. We made a recommendation about this.

We found improvements were needed to aspects of care to ensure that it was always person-centred. Staff knew people well and understood their needs. People were supported to take part in a range of activities throughout the day. There was a complaint policy and we saw this was followed appropriately.

Visitors were welcomed at the home. People were able to receive visits from their named visitors. Some people received visits from relatives who were essential care givers. Essential care givers are relatives or friends who are able to spend more time with the person to help meet their physical and emotional needs. Visiting usually took place in a lounge which had been converted to a visiting room. Dependant on people’s needs, some visits took place in the person’s room. Garden visits were also available. Throughout the pandemic, where people were considered to be end of life, they were able to receive regular visits from family in their bedrooms. Visiting was on an appointment system to allow time for appropriate cleaning between visits and keep the home safe from the risk of infection. Most visits took place during weekdays but where people were unable to visit during the week, then weekend appointments were supported. All visitors were required to have a rapid Covid-19 test before the visit. During the visit they wore the appropriate personal protective equipment (PPE).

People were protected from the risks of harm, abuse or discrimination because staff knew what actions to take if they identified concerns. There were enough staff working, who had been safely recruited to provide the support people needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

There was one person with a learning disability living at Mulberry House. This service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• To provide continuity the person received support from the same staff, as far as possible. Staff supporting the person were knowledgeable about the person and the support they needed.

Right care:

• The care was person-centred and promoted the person’s dignity, privacy and human rights. Staff had worked with the person to increase their independence and confidence to try new things. The person was supported to go out every day to help maintain their functional skills.

Right culture:

• The management team and staff had worked with external professionals, including the community learning disability team to help ensure the person received the appropriate support. Staff spoke about this person with enthusiasm and affection and were proud of how far the person had come.

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 3 December 2019). There were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve. The service remains requires improvement.

Enforcement

We have identified a breach of regulation in relation to Quality assurance systems and aspects of record keeping at this inspection.

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

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. This enabled us to review the previous ratings.

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 Covid-19 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 re-inspection programme. If we receive any concerning information we may inspect sooner.

Mulberry House is a residential care home providing personal and nursing care for up to 72 people. The home is divided into two units. The Queen Mary unit provides nursing care for people living with healthcare needs such as stroke, heart disease diabetes and dementia. The Mulberry unit provides nursing care and support for people living with an acquired brain injury. This can be because of an accident or following a health-related condition, such as a stroke or Parkinson's disease. There were also some people, with a learning disability.

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

The quality assurance systems did not identify all the areas for improvements which we found. People’s records did not always reflect the care and support they needed and received. Improvements were needed to ensure risks to people in relation to some aspects of medicines management and risks related to their health and well-being were managed safely. We also asked the provider to make improvements to their recruitment procedures.

People’s care plans were not always followed, and others did not include enough information to demonstrate people’s needs were met. We made a recommendation about this.

People were supported by staff who treated them with kindness and compassion. Staff understood people’s needs, choices and knew what was important to each person. People were enabled to make their own decisions and choices about the care and support they received.

People were supported to take part in a variety of activities that they enjoyed and were meaningful. Complaints were responded to effectively. People’s communication needs were assessed and responded to.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff received the training and support they needed to help them look after people effectively. They received training specific to meeting people’s individual assessed needs.

Nutritional assessments had been completed and identified the type of diet and support people needed. Staff were aware of people’s dietary needs. The registered manager had identified improvements were needed in relation to the food that people received and this was reflected in the mixed feedback we received.

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 good (published 13 December 2018). Since this rating was awarded the provider has altered its legal entity. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected

The inspection was prompted in part due to concerns received about the care people received and staffing levels. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvement. Please see the safe, responsive and well-led sections of this full report.

Enforcement

We have identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to aspects of safety, people’s records and the quality assurance system at this inspection.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Queen Mary's and Mulberry House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Queen Mary's and Mulberry House Nursing Home provides accommodation and nursing care for up to 72 older people and younger people, some of who had physical disabilities. At the time of the inspection there were 59 people living at the home. Queen Mary's and Mulberry House Nursing Home is run as one and the home is divided into two units. Queen Mary's provides nursing care for people living with healthcare needs such as stroke, heart disease diabetes and dementia. Mulberry House provides nursing care and support for people living with an acquired brain injury. This can be because of an accident or following a health-related condition, such as a stroke or Parkinson’s disease. There were also some people, with a learning disability, living at the home. Most of whom also had an additional nursing need.

There were some people at the home living with a learning disability. CQC have developed guidance for homes who look after people with a learning disability. This is called Registering the Right Support. We have written to the provider to ask how they will develop the service to ensure it embraces the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. This is so people with learning disabilities and autism using the service, can live as ordinary a life as any citizen.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We had previously carried out an inspection in April 2016 where we rated the service as good, although we asked the provider to make improvements in relation to the recording and management of wounds. At this inspection we found improvements had been made in relation to wound management and the evidence continued to support the rating of Good. We found improvements were needed to some aspects of record keeping. However, there was no evidence or information from our inspection, and ongoing monitoring, that demonstrated serious risks or concerns.

This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Improvements were needed to ensure people’s records always reflected the care and support they needed and received. Staff knew people well and had a good understanding of them as individuals and the care and support they needed. People received care that was person-centred and met their individual needs and choices. Activities were developed to meet each person’s needs.

People were supported by staff who were kind and caring. They treated people with kindness, understanding and patience. People were supported to make decisions and choices about what they did each day and their dignity and privacy was respected.

People’s safety was maintained because staff had a good understanding of the risks associated with the people they looked after. Risk assessments were in place and provided guidance.

People’s medicines were ordered, stored administered and disposed of safely. They were protected from the risks of harm, abuse or discrimination because staff had a good understanding of safeguarding procedures and their own responsibilities. There were enough staff working to provide the support people needed. Recruitment procedures ensured only suitable staff worked at the home.

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.

There was a training programme for staff and they received regular supervision and appraisals.

People were supported to eat and drink a choice of food that met their individual needs and preferences. Their health and well-being needs were met and they were supported to have access to healthcare services when they needed them.

Complaints had been recorded, investigated and responded to appropriately. There were effective systems to assure quality and identify if any improvements to the service were needed.

Queen Mary’s provides nursing support for people living with varying stages of dementia along with healthcare needs such as Parkinson’s, diabetes, strokes and heart disease. Mulberry House cares for people with an acquired brain injury, this included post trauma as well strokes. There was a multi-agency approach to care and support which included physiotherapists and occupational therapists working alongside the care team. The age range of people living at the home varied from 23 –100 years old.

Accommodation was provided over two floors with lifts that proved level access to all parts of the home. Thought and consideration had been given to the environment of the home, making it as comfortable and user friendly as possible. People spoke well of the home and visiting relatives confirmed they felt confident leaving their loved ones in the care of Queen Mary's and Mulberry House Nursing Home.

A manager was in post and was in the process of registering with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection on 28 January and 02 February 2015 we asked the provider to make improvements to the safety and welfare of people, infection control procedures treating people with dignity and respect, ensuring equipment was properly maintained and the monitoring and assessing the quality of the care and support provided. The provider sent us an action plan stating they would be addressed by December 2015. We found our concerns had been addressed and the breaches in regulation met.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

Care plans reflected people’s assessed level of care needs and care delivery was person specific and in line with the care plans. The delivery of care was based on people’s preferences.

The care planning system had been reviewed and records for each person were specific to their needs, with guidance for staff to ensure people received the support and care they needed and wanted. We saw care plans that contained information about people’s skin integrity alongside the risk assessment to identify people’s individual risk to pressure ulcers. However we did find gaps in documentation that identified that some people’s skin had deteriorated to a wound without changes to the risk assessment or care plan. There was no indication of staff awareness of the development of the wound. This was discussed in full and as requested a full root core analysis was undertaken by the manager with timelines of the pressure wounds following the inspection.

Risk assessments included, falls, skin damage, behaviours that distress, nutritional risks including swallow problems and risk of choking and moving and handling. For example, cushions were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy.

Nurses were involved in writing the care plans and all staff were expected to record the care and support provided and any changes in people’s needs. The manager said care staff were being supported to do this and additional training had been arranged. Food and fluid charts were completed and showed people were supported to have a nutritious diet.

Staff had a good understanding of people’s needs and treated them with respect and protected their dignity when supporting them. A range of activities were available for people to participate in if they wished and people enjoyed spending time with staff. People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with smiles. People previously isolated in their room were seen in communal lounges for activities, meetings and meal times and were seen to enjoy the atmosphere and stimulation.

Activity provision was provided throughout the whole day and was in line with people’s preferences and interests.

The provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed including those for care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service and relatives told us they could visit at any time and they were always made to feel welcome and involved in the care provided.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. The provider was actively seeking new staff, nurses and care staff, to ensure there was a sufficient number with the right skills when people were able to move into the home. The manager told us it had been difficult to recruit nurses with the right knowledge, a deputy registered manager had been appointed and the provider continued to advertise for full time nurses.

Pre-employment checks for staff were completed, which meant only suitable staff were working in the home.

The provider had made training and updates mandatory for all staff, including safeguarding people, moving and handling, management of challenging behaviour, pressure area care, falls prevention and dementia care. Staff said the training was very good and helped them to understand people’s needs.

All staff had attended safeguarding training. They demonstrated a clear understanding of abuse and said they would talk to the management or external bodies immediately if they had any concerns, and they had a clear understanding of making referrals to the local authority and CQC. People said they were comfortable and relatives felt people were safe.

Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people’s needs were met. There were systems in place for the management of medicines and we observed staff completing records as they administered medicines.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider, registered manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Staff said the management was fair and approachable, care meetings were held every morning to discuss people’s changing needs and how staff would meet these. Staff meetings were held monthly and staff were able to contribute to the meetings and make suggestions. Relatives said the management was very good; the registered manager was always available, they would be happy to talk to them if they had any concerns and residents meetings provided an opportunity to discuss issues with other relatives and staff.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. We spoke with five people who lived at the home, one relative and four members of staff, including the registered manager. We also spoke with a community nurse who was visiting the home.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found

Is the service safe?

People were treated with respect and dignity by the staff. People who used the service told us they felt safe. A relative told us, "It's a real comfort to know that mum is safe and well cared for."

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The registered manager compiled the staff rotas, they took people's care needs into account when they made decisions about the numbers, qualifications, skills and experience required. This helped ensure that people's needs were always safely met.

Policies and procedures were in place to make sure that unsafe practices were identified and people were protected.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people were safeguarded as required.

Is the service effective?

People's health and care needs were assessed with them, and, as far as practicable, they were involved in developing and reviewing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

People and their relatives said that they had been involved in reviewing care plans and they reflected their current needs.

People's needs were taken into account with the accessible layout of the service, enabling people to move around freely and safely.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

The home had systems in place to assess and manage risks and to provide safe and effective care. The staff were appropriately trained and training was refreshed and updated regularly. Staff could also take the opportunities provided to study for additional qualifications and to develop their understanding of caring for people with conditions such as dementia and mental health illnesses. We also found evidence of staff seeking advice, where appropriate, from the GP or social services.

Is the service caring?

People were supported by kind and attentive staff. We saw that all staff that had contact with the people who used the service showed patience and empathy. A person who used the service told us, "Everyone here is so kind and helpful ' I'm very satisfied."

We spoke with relatives who said they were able to visit at any time and they were always made to feel very welcome. They told us 'Whenever I visit there are always staff around and they are kind, friendly and provide good quality care.' We saw that the staff took time with people over lunch and when they were moving about within the home. We observed high levels of respect and people were treated sensitively with consideration and dignity.

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People had the opportunity to take part in a range of activities, reflecting their interests and preferences, both in and outside the service. A care worker told us "We spend time with people and get to know them individually, so we can find out what their interests are and how they like to spend their day.'

People's needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed regularly. This ensured that the care and support provided reflected any identified changes in people's individual care needs. We saw that the staff monitored weight, nutrition and hydration and handover sessions were helpful and informative.

We were told by the organisations director and deputy manager that the service had good systems in place to monitor its own standards of service delivery and to gain feedback from people who used the service, their relatives and other stakeholders. As well as satisfaction questionnaires, the deputy manager told us they operated an 'open door policy' so people who used the service and visitors to the home could discuss any issues they may have.

People told us they were asked for their feedback on the service and their feedback was heard and changes were made as a result. People and their relatives, who we spoke with, also knew how to make a complaint or raise any issue or concern that they might have. They were also confident that their concerns would be listened to and acted upon.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up and consistent way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in. They also told us that they felt valued and supported by the management team and were happy and confident in their individual roles.

People were enabled to express their views and were involved in making decisions about their care and treatment. We found that care and treatment was planned and delivered in a way that ensured people's safety and welfare. Medicines were prescribed and given to people appropriately and safely. There was enough specialised equipment to promote the independence and comfort of people who used the service. We saw documentation that the provider responded appropriately to any allegation of abuse. There were enough qualified, skilled and experienced staff to meet people's needs. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We saw that complaints were taken seriously and there was an effective complaints system available.