Archived: The Moorings Retirement Home

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Inadequate

• Caring

  Inadequate

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

We carried out a responsive assessment of The Moorings Retirement Home between 28 April and 9 June 2025.

The Moorings Retirement Home is a care home providing accommodation and personal care for older adults, some of whom were living with dementia. It is registered to accommodate up to 40 people. At the time of the assessment there were 38 people residing at the home.

This assessment included 3 site visits, 2 of these visits were conducted out of hours. Four inspectors and a medicines inspector were involved in 1 or more of the assessment site visits completed. An expert by experience supported the assessment and carried out remote communication with relatives of people living at the home.

At the last inspection in February 2022, we rated the home as good. This latest assessment was undertaken due to the receipt of information of concern in relation to people being woken from bed early in the morning. Concerns were also raised regarding staffing, governance and oversight arrangements. We found the concerns were substantiated. The service is now rated inadequate.

The provider was in breach of 8 legal regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and 1 legal regulation under the Care Quality Commission (Registration) Regulations 2009 (Part 4) (as amended). These related to person centred care, need for consent, safe care and treatment, safeguarding, premises and equipment, good governance, staffing, fit and proper persons and failure to notify CQC about incidents that affect the health, safety and welfare of people who use services.

The care being provided to people was not person-centred and records failed to demonstrate care provided to people took into account their needs and preferences.

We were not assured that baths, showers and oral hygiene were regularly offered or provided to people to maintain their basic hygiene needs and ensure they were supported in a dignified way. People were not always treated with compassion and dignity by staff.

The provider failed to demonstrate they sought consent or enabled people to make decisions in line with the legal framework. Processes for safe care and treatment were ineffective and placed people at risk of avoidable harm. The provider failed to adequately assess risks relating to falls. Safeguarding concerns and complaints were not always logged; and there was no evidence of analysis of themes and trends so as to support learning.

The provider failed to implement effective systems to assess, monitor and improve the service. We were not assured staff were always suitably trained and the provider’s oversight of training was not effective in ensuring staff received training appropriate to their role in a timely manner.

Safe recruitment practices had not been followed and we identified shortfalls in relevant required checks.We were not assured that staffing levels were safe or sufficient to meet people’s physical and mental health needs particularly overnight

The provider did not have effective governance systems in place to monitor and improve the quality of the service. We also noted a failure to, as required, notify CQC of specific events. Environmental risks were not monitored and managed effectively and people were placed at avoidable risk of harm through lack of risk mitigation. Care plans were not person-centred, accurate or up to date.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

During the inspection we spoke with 12 people and 13 relatives, this included communication with relatives off site.

We received mixed feedback from people and their relatives about their experiences of the service and the care provided. Some people and relatives spoke warmly about the care staff delivering care. However, others felt there were aspects of the service that needed improvement.

During our assessment we found significant shortfalls in people’s experience of care, such as neglect of people’s personal care delivery. We made observations at this assessment and found elements of care did not always meet the expected minimum standards. Shortfalls included people not being served food in line with their assessed dietary needs and risk management requirements. People’s experience of care was not always person centred.

Where people at the service were living with dementia, we observed the environment did not always reflect best practice to support people with orientation around the home. People were not supported to engage in meaningful activities and appeared to have limited interaction.