Moorlands Lodge Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulation in relation to governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. The registered manager stated, “The values of Avery are to make the home a great place to live and to work. To support each other and for people to like living here.”

The provider encouraged staff to develop their skills and the management team supported them through this. For example, 6 care staff were undergoing a vocational qualification. The senior staff were encouraged to develop their skills in a range of areas such as writing and updating care plans and completing documentation such as CQC notifications. The registered manager added, “We let the staff know what training is available so they can complete this. During one to ones, we identify what staff need and listen to them.”

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had experience of working in health and social care and was a qualified nurse. They had been in post for 11 months and were keen on developing the home in order to benefit people and the staff team. They told us they received good support and enjoyed their work. They said, “I am well supported by my manager. We have a weekly call and [they] come in once a month. I have a regional support manager who comes in once a week.”

Staff’s opinion about the registered manager and management team varied. Most staff found them to be visible and supportive and most felt valued and supported. Their comments included, “[Registered manager] is approachable and will always listen” and, “Yes the managers are approachable, listen to staff and ensure fairness across the team.” However, others reported, “When short staffed, managers used to help. Now they’re always in their office. We don’t see them” and “I feel that staff are under a lot of pressure. When asking for support, we are sometimes told to just get on with it… I feel that there is sometimes a blame culture.”

We fed this back to the registered manager who they told us, “The general manager undertakes regular walkabouts across all units, directly engaging with staff, offering practical assistance, and maintaining clear oversight of the care environment. This visibility supports a culture of openness, accessibility, and responsive leadership… Managers routinely spend time on the floor throughout the day, completing audits, observing practice, supporting staff, and interacting with residents and their families.” They added, “In addition to their leadership functions, managers provide hands-on support to the care team where needed.”

There were regular team meetings and management meetings where a range of subjects were discussed and information was shared. A staff member told us, “Meetings are held each month. They are very good and [Registered manager] likes to make these different every time, different agenda, appreciation for staff and quizzes for team building.”

In addition to team meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint. The registered manager told us, “Each department also has their own meetings. Staff are supported with their one to ones and are supported to raise any concerns. We discuss in staff meetings how they can raise concerns if they want. They have whistleblowing information. They can escalate anything they want to. My door is always open. I work together with them to try to find solutions.”

Staff said they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home.

The provider had processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

The provider valued diversity in their workforce. They told us they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they enjoyed working in a diverse team. Whilst almost all staff reported they were treated fairly by their colleagues and management, a minority of staff told us this was not the case. Their comments included, “I don’t feel that the workload is fair or the staffing. Quite often, I work with [staff] who cannot do the full job, or carers who can’t attend to certain residents, therefore it leaves me to do a lot more of the work” and, “I’m always working in dementia care and I was never given the opportunity to work on any other floors. I have noticed all my colleagues work on all the floors…I feel discriminated in many ways.” We fed this back to the registered manager. They assured us they would look into these concerns.

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment.

Staff who had healthcare needs were supported appropriately. The registered manager told us they met with them regularly to establish how they were feeling and how they could meet their needs within the workplace.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had monitoring systems in place. However, these had not always been effective and had failed to identify the concerns we found during our inspection.

There were shortfalls identified in the management of medicines. Medicines audits were regularly undertaken but had not identified these shortfalls. This put people at risk of not having their pain and healthcare conditions effectively managed.

Systems were not always in place to ensure people’s rights were protected and the principles of the Mental Capacity Act 2005 (MCA) were followed. Decision specific capacity assessments were not always completed to determine people’s capacity. Where people were found to lack capacity for specific decisions best interest decisions were not always recorded.

The registered manager submitted a ‘Sustainability plan’ weekly to their line manager to keep them informed and highlight any areas of concern. This provided up to date information about a range of areas such as training, medicines management, notifications and supervision of staff.

The registered manager and clinical lead were given feedback in relation to the medicines concerns identified. They were responsive and took this feedback seriously. They took appropriate action to make the necessary improvements and learn from the concerns, by communicating with the staff and upper management, and put more robust systems in place. In addition, they reviewed their policies to make these more robust.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals.

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they had put in place an information pack for each person. This was to prevent communication being lost when a person was admitted to hospital. They ensured this was sent with the person so the hospital staff had the information straight away.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

People said they were consulted during meetings, reviews or regular conversation to find out if they had any concerns or requests. Relatives said they were aware of and invited to meetings. A relative told us, “[Registered manager] has had a couple of meetings, open forum meetings. I think they’re all approachable here.” A person added, “The manager is very nice. [They] came to see me when I arrived. In fact, all staff at all levels are great.”

The registered manager told us they listened to people’s feedback and made the necessary improvements. They responded positively to concerns raised and shortfalls in the service being identified during auditing processes. They worked alongside the provider to develop a service improvement plan and to work with the local authority and safeguarding teams to address issues raised in relation to past medicines errors.

The provider conducted a yearly survey for all staff. The result of the most recent survey was mixed, where some staff reported to be very happy and others not. The registered manager took their concerns seriously and responded to the concerns with actions they had taken to improve.