Moorhouse Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding people from abuse and the lack of robust recruitment processes.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders did not have a proactive and positive culture of safety based on openness and honesty. Leaders did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was no analysis of people’s periods of emotional distress to look for trends and themes to reduce further risks. These incidents were not always recorded and where they were, there was not sufficient detail in order to determine how the incident occurred or why. We were also made aware of an incident where the registered manager had intervened with a person who was displaying high levels of emotional distress. The registered manager told us they intervened as the person was throwing items at other people. The provider’s policy was not followed to ensure the incident had been recorded accurately and had only been recorded on a behaviour chart.. The behaviour chart contained an inaccurate account of the incident.

The ‘falls and incidents’ audit for May 2026 reviewed the trends and themes for incidents that month. However, the data used did not reflect the incidents recorded on the incident tracker provided to us for May 2026. It stated on the audit there had been 11 altercations between people and that 6 had involved the same person. However, according to the incident tracker, only 3 instances had involved this person. In addition, there was no information on what learning there had been in relation to all 11 incidents. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. The registered manager told us they needed to undertake more work around the recording and the discussions on learning from incidents.

However, we did see where falls had occurred, action was taken at the time to ensure people were supported. One member of staff told us, “If there’s a witnessed fall, we will inform the team leader and write an incident form, and they will do their part. We do have sensor mats and when there’s a fall or accident the team leader will call 999 if there is an emergency or any bruises.”

Leaders did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Whilst the leadership team had undertaken assessments of people’s needs before they moved into the service, these did not always provide guidance for staff on how to support people in a safe way. For example, 1 person’s assessment had been completed in the hospital with a member of hospital staff. It was recorded in the assessment that the person could express their needs both physically and verbally. However, no action was taken to speak to the person’s family to explore this further to determine what the possible triggers could be. The person had been admitted to the service without full information about their emotional distress. The registered manager told us up until June 2026, the person had been experiencing frequent emotional distress. The registered manager told us they felt some discussions had not been open and transparent about the person’s needs however, as stated, there were missed opportunities to gain more information from the person’s family.

We reviewed some pre-assessments that had provided more detail around people’s preferences and needs. A relative told us, “[Family member] was in hospital. I came here [to the home] and met [registered manager]. She was amazing. She arranged for [family member’s] room to be rearranged just how she likes it. There was good communication. [Senior staff member] visited [family member] in the hospital and sat a long time chatting to her.” A member of staff told us, “Managers and deputies do the assessment so when they arrive, we have the information, we check their discharge letters, set up [medicine] charts and register with the GP so everything is in place.” Another member of staff told us, “We will get an overview of any new people. We can also speak to team leaders, and we will have the basics on care system. They add to it as time goes on.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Systems were not effective to ensure people were protected from the risk of abuse, or avoidable harm and caused impact for some people. When incidents of harm or abuse occurred, leaders did not consider the emotional impact on the person, other people and staff. We saw incidents where people had physically assaulted other people. Leaders had not taken sufficient action to investigate the abuse or taken action to protect people from further harm. We identified 7 incidents of physical and verbal abuse from person to person which resulted in injury that leaders had not raised with the local authority safeguarding team or notified CQC as legally required.

Staff told us they would report any safeguarding concerns to their line manager and escalate this if no action was taken. One said, “We are always reminded of safeguarding at every team meeting. I would always report to team leader first, if no response through management, CQC, local authority or the whistle-blowing hotline.” We found they were not always doing this when issues arose.

However, there was positive feedback from people that they felt safe at the service, including, “The staff are kindness themselves”, “(Staff are) very kind and lovely people”, “They don’t make you do what you don’t want to do. I feel nothing nasty will happen here.” A relative told us, “I used to worry about [relative] incessantly, but I don’t think about it anymore.” We also observed on the day that people appeared relaxed in the presence of staff.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.
We found leaders did not always ensure the legislation was complied with as some people were subjected to restrictions without the appropriate legal authority. For example, the registered manager told us 1 person was experiencing high levels of distress in the lounge. This person was unlawfully restricted by having their wheelchair moved from the lounge to the their room without their consent. There was no DoLS authorisation in place for this restriction.

There were people that had sensors on their beds and sensor mats. However, there were no capacity assessments or best interest discussions which had been recorded in relation to this. There were no DoLS authorisations in place for these restrictions where people lacked capacity.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People did not always feel involved in the management of their health risks. They said when health checks were undertaken by external professionals, they were not updated on the results.
Where people were at risk of constipation, dehydration and malnutrition, although there were risk assessments in place, there was a lack of monitoring of people’s outcomes. For example, we saw from 2 people’s nutritional assessment that staff were to offer frequent and regular meals. However, the care notes showed this was not taking place and they were only offered food at the normal mealtimes. These people continued to lose weight or did not gain weight as required by the care plan. Where people were required to be weighed weekly, this was not always happening. This placed people at further risk of malnutrition.

This lack of robust monitoring was also not in place for people who had fluid intake targets set. We saw people were often not reaching anywhere near these targets. For example, 1 person’s target was to have 1500 mls per day. However, their care notes over 6 days showed that more often than not, they were only having less than 600 mls per day. On one day it was recorded the person only had 227 mls. This placed people at further risk of dehydration. We also saw from bowel charts that staff were not always escalating to leaders where people at risk of constipation, had not opened their bowels for a number of days.

We raised the concern with the lack of monitoring of people’s bowels, fluid and nutrition with leaders who told us they had taken immediate action to address this. We also fed back to leaders that there was an inconsistent approach by staff on clearly explaining the process of being hoisted to reduce the risk of anxiety.

However, we did find other risks associated with people’s care were managed in safe way. This included the management of falls, skin integrity and intolerance to foods. We observed that where people needed to be repositioned to reduce the risk of pressure sores, this was being done. One relative told us, “[Family member] has the physio come in [which the home sorted]. She gets everything she needs. They understand her mobility and how she needs support with that.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People benefitted from an environment that was adapted to suit their individual needs. The flooring throughout was clean and free from obstruction. Window restrictors were in place and functional, both in communal areas and in people’s bedrooms. There were adaptable showers and bath equipment for people so those using wheelchairs could bath or shower. One member of staff told us, “We have enough hoists and equipment. We’re never waiting for equipment.”

Records showed that health and safety checks were carried out regularly. These included electrical installation, gas safety and water management. Care equipment such as moving and handling aids were serviced and records of maintenance kept.

The service had ensured actions had been taken to safely evacuate people in the event of an emergency including personal emergency evacuation plans to guide staff to support people to leave their home safely. Fire drills, to check staff had the practical skills needed, had taken place with all staff. The service had ensured that people had the equipment in place to safely evacuate them in the event of a fire, and there was clear and appropriate signage to the fire doors and exits.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were mixed responses from people and relatives about whether they felt there were sufficient staff at the service. One person told us they often had to wait 15 to 30 minutes before staff supported them to the bathroom. Other comments included, “You have to wait a long time [for staff] after lunch to come back upstairs and I don’t like it. I guess staff go on their breaks so there aren’t any around. I am also put to bed at 6 thirty. It’s a bit earlier for me”, “They [staff] come quickly if I use my bell”, “There are absolutely enough staff. There’s always someone around” and “I think there are enough staff, they work very well.”

We observed that during the morning there were sufficient staff to support people. However, after lunch particularly when staff were taking their breaks, there were periods of time where staff were not present in the lounge. We saw a person was attempting to pull the flex from the fan (which was not switched on) towards them in the corner of the corner and there were no staff around to observe this.

Staff told us there were usually enough staff to keep people safe but felt there was not sufficient time to spend with people in a meaningful way or offer showers and baths when people wanted. Comments included, “We could do with 1 more. It’s fine getting people up, washed and dressed in the morning, but there are times we could socialise with them more during the day”, “I have said to the management I think we need more staff as it’s not person-centred. If I want to spend time in people’s rooms or go for a walk there won’t be anyone to keep an eye on people in the lounge” and “We don’t get to give them showers and such as there is too much do.”

Staff were provided with appropriate training; however, we saw that supervisions were not always carried out as planned. Leaders told us there was an action plan in place to address this.

The provider did not operate effective and safe recruitment practices when employing new staff. Employment history was not always recorded, and the provider did not have references on file for all staff. This meant the provider could not assured of the staff suitability to work at the service.

The provider did not always assess or manage the risk of infection.

Infection, prevention and control practices that were not always safe. Leaders told us that each person had their own individual slings for when they were supported to transfer using a hoist. Slings are considered high-risk for cross-contamination. Using a shared sling can transfer harmful bacteria, viruses, or fungal infections between people. We observed staff using the same sling for 3 people when they were being supported to transfer using a hoist in the lounge. We fed this back to the leadership team who confirmed that this was not expected practice and people had their own individual slings. They told us they were taking action to address this. We also observed that in 1 of the sluice rooms, the sink had debris in the plug hole indicating it was not being used. There was also soiled continence equipment stored in there.

People were not always supported to maintain their personal hygiene and appearance. On review of the bath and shower records, there were some people who were not offered a bath or shower for several days and instead were given a ‘bed bath’. One person told us, “I had a shower today and I don’t know when I will be offered again.” A member of staff told us, “I think hygiene is important and if I’m honest, they probably could do with more showers.”

The remaining environment appeared clean and tidy and there were no malodours on the other floors. The laundry room was set up well to ensure good infection control. We saw staff cleaning the service throughout the day. One person had an accident in the corridor and staff immediately washed and disinfected the floor. One member of staff told us, “We have workstations with all the masks, aprons, gloves and bags. If there is barrier care, a note is put on their [person’s] door.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they received their medicines when needed. One person said, “They (staff) stand with you until you’ve taken all of them.”

People’s medicine records were digital and were detailed with how they wanted to be supported to take their medicines. Medicines were stored safely, in a secure, temperature-controlled environment and medicines were disposed of safely as required and in accordance with the provider’s policy. We did raise with leaders that there were some guidance missing for people that had recently been prescribed ‘as and when’ medicine. For other people’s ‘as and when’ medicines, for example, pain relief, there was information for staff about these, such as what they were for and when they should be offered to people.

Medicines were reviewed when required with people, the GP, and other health care professionals involved in their care. The medicine rooms were clean and well-organised. The medicines trolley was clean, and each person’s medicines were in individual labelled boxes.