Archived: Mulberry Manor

Updated 5 January 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the registered provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 11 October 2017 and was unannounced. The inspection team consisted of two adult social care inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Prior to the inspection visit we gathered information from a number of sources. We looked at the provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We looked at notifications sent to the Care Quality Commission by the registered provider.

As part of this inspection we spent some time with people who used the service talking with them and observing support. We looked around the service including bedrooms, bathrooms and communal areas.

We spoke with the regional manager, the registered manager, the deputy manager, the team leader, care staff, catering staff, the housekeeper and a domestic. We also spoke with eight people who used the service and seven visiting relatives. Observations helped us evaluate the quality of interactions that took place between people living in the home and the staff who supported them.

We looked at documentation relating to people who used the service, staff and the management of the service. We looked at six people’s care records. We also looked at the systems used to manage people’s medication, including the storage and records kept. We also looked at the quality assurance systems to check if they were robust and had identified areas for improvement.

Updated 5 January 2018

The inspection was carried out on 11 October 2017 and was unannounced. This meant the registered provider and staff did not know we would be visiting. The service was inspected in August 2016, where concerns were identified in relation to how risk and medicines were managed at the home; safeguarding; people’s care and welfare; how the provider ensured consent was legally obtained; how people’s dignity and privacy was upheld; and the governance of the service. We took enforcement action against the provider and told them that they had to make improvements to the service. We also placed the service into special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the registered provider’s registration of the service, will be inspected again within six months.

We then inspected on 23 February 2017 to determine if improvements had been made. At this inspection the service remained in special measures, as we judged that although the service was overall rated requires improvement, the service remained inadequate for the key question of “Effective”. At this inspection we found some improvements and there is no key question rated as Inadequate so the service is removed from special measures. However, they remain in continued breach of three regulations in relation to how risks and medicines were managed at the home, how the provider ensured consent was legally obtained and the governance of the service.

The service had a registered manager. 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

Mulberry Manor is a 49 bed care home, providing personal care to older adults with a range of support and care needs. At the time of the inspection there were 25 people living at the home. The home is divided into two units.

Mulberry Manor is located in Rotherham, South Yorkshire. It is in its own grounds in a quiet, residential area, but close to public transport links.

The provider had safeguarding procedures and staff were aware of the procedures. Staff had received training and people were protected from abuse.

Systems were in pace to manage medicines safely. However, we found these were not always followed to ensure people received medications as prescribed.

Assessments identified risks to people and management plans to reduce the risks were in place to ensure people’s safety. However, we found these were not always followed.

Staff we spoke with expressed concerns in relation to the overall leadership and management of the service, but said that they were well supported by the unit manager and deputy manager. They confirmed they received training that was required to fulfil their roles and responsibilities.

People who used the service, and their relatives we spoke with, told us they were happy with how the care staff provided the care and support. They spoke positively about the staff and told us they were caring.

The meals provided were well presented, nutritious and appetising. However, the meal time experience did not meet people’s needs who were living with dementia.

People did not always receive personalised care that was responsive to their needs.

At the time of our inspection we found there was sufficient staff on duty to meet people’s needs.

The service was clean. However, we identified some poor hygiene practice that put people at risk.

We found the service was not always meeting the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some records were well completed and clearly documented the decision being made. However, we found some people’s best interests were not always documented; this was identified on both units. If they were documented they did not always involve all relevant people and did not clearly detail the outcome. Decisions being made were sometimes very general and not specific.

People and the relatives we spoke with were aware of how to raise any concerns or complaints and felt listened to. Quality monitoring questionnaires were sent out and the responses had been collated with actions.

The provider had systems in place to monitor the quality of the service. The manager completed several audits such as medication, infection control, staffing, building and premises, and health and safety. We found that some audits had not identified the concerns we highlighted as part of our inspection.

We found three continued breaches and one additional breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the end of this report.