Working at Mulberry House

The provider did not have a proactive and positive culture of safety. They did not listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice. For example, we found 2 fire risk assessments had been completed in the past 4 years, both identified actions to improve safety. The provider had not acted upon these assessments.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Where people needed equipment to support their mobility and transfers, we found staff had not received appropriate training in how to use the equipment nor had they been assessed as competent.

We identified shortfalls in the providers systems to ensure staff had received competency assessments and records were accessible to staff. For example, staff told us they had received competency assessments by a member of the management team, however when we spoke to the management team member, they were unable to provide these records.

Governance systems failed to identify the concerns found during this inspection. The provider had not learned lessons from previous inspection to drive improvement in the service.

Relatives told us activities and outings in the community were limited. One relative said, “[Person] could do with more (activities), an improvement they could do.” Another said, (in answer to if there is enough activities) “No, goes to a club on Mondays and that’s about it, its hit and miss sometimes”.