‘Inadequate’ Luton care home placed in ‘special measures’ after breaching regulations

Mulberry House looks after eight people at the home in Barton Road.

​The CQC put the home under special measures after it failed to make improvements despite repeated concerns being raised.

The report deemed the home ‘inadequate’ following a month-long inspection earlier this year.

A spokesperson for Complete Care Services Ltd, which runs the home, said they were “deeply disappointed” adding many improvements had been made since the inspection.

They said: “We do not accept all the findings and are in the process of challenging the resulting regulatory action. Throughout this most recent inspection process, we have cooperated with the CQC and provided all information required. We have and will continue to challenge the inspection findings, as well as CQC’s approach to the inspection and process afterwards.”

The report, released today (September 19), outlined the failings of the home and gave clear areas for improvement.

A particular area of concern was the safety of the residents, with the provider showing a “reactive safety culture, failing to act on fire risk assessments and not having a proactive plan to address safety concerns, which increased the risk of harm to individuals.”​

The report stated: “We identified fire doors were held open with objects such as laundry baskets and boxes, this prevented them from automatically closing in the event of fire, we also noted all fire doors in the service were defective, which had also been highlighted in the past two fire risk assessments, and all showers in the service could reach high temperatures which presented a scalding risk.”

The CQC said that the home had since replaced the fire doors and showers after their inspection. The provider said: “Over the past few months, we have focused on embedding meaningful improvements and are seeing clear progress in the right direction. Residents remain at the heart of everything we do.”

The inspectors also found that relatives were waiting for social services to give them extra funding to replace furniture.

The CQC’s report explained: “This is not the responsibility of social services and should be undertaken by the provider. This lack of clarity limited people’s understanding of the issues they could raise.”

Inspectors also found that infection risks were not controlled. The report stated: “We found multiple areas of the service were unclean. For example, en-suite bathrooms had evidence of mould and rusty handrails. Where surfaces had become damaged, for example with wooden furniture, they could not be effectively cleaned.”

Despite the damning findings, the CQC did find that people generally felt safe and were treated kindly: “One person said, ‘I feel safe. I feel safe in my room and come down when I want to see other people or staff.’”

Staff at the home were described as caring. One person said: “The staff here are kind, I get along with them all.”

And those working at the home said they “were happy working in the service” and “felt supported by the management team”.

The provider was criticised for “not always [promoting] people’s independence”.

The report stated: “...one person said, “I like cooking, but I do not go into the kitchen as it is always locked. I made cakes at the last place but haven't done it here. Made a Korma when I first moved in and that’s it.”

“There was no evidence this risk had been assessed or that it was in the person's best interests to be denied access to the kitchen.

“Another person said, “The kitchen is always shut”. Locking the kitchen denied all other people in the service access to the kitchen. This meant people had their independence, choice and control taken away from them.”

A spokesperson for Complete Care Services Ltd, which owns the home, said: “Mulberry House has been operating for approximately 23 years now and we are proud that during that time, residents have been happy to call the service their home. We are committed to ensuring that our residents and their families are happy and satisfied with the service provided at Mulberry House.

“…we do accept that in certain areas of the service, improvements are required; we have made and continue to make the necessary improvements. Within two weeks of the inspection, all safety concerns highlighted by the CQC had been fully addressed and evidence of such was comprehensively provided to the CQC. We also immediately arranged for a mock inspection to take place by a highly respected and experienced care consultancy company, so we could fully ascertain the issues at the service and even go beyond what was identified by the CQC.

​”The [report] relates to an inspection that took place in May 2025. Four months later the service is in a different position. Many improvements have been made to the service in the intervening months since May, with a real focus upon improving processes and ensuring that all documentation provides an accurate and up to date picture of the service and most importantly, the residents that live there.

"To support this, we’ve significantly increased our investment in technology — and we’re already seeing the positive impact. From an oversight and governance standpoint, improvements are measurable, sustainable and regularly audited— all under the supervision of the Registered Manager and the Senior Management Team.

​”We would like to reassure residents and their families that the service is safe and we categorically refute any suggestion that residents are at risk. While these challenges have been raised and we are fully aware of the CQC’s concerns, we have taken proactive steps to address them.”