Archived: The Moorings Retirement Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

We assessed 6 quality statements within this key question. We identified 1 breach of Regulation. Consent to care and treatment was not always sought in line with legal requirements and guidance. The provider had failed to ensure they consistently met their legal requirements to assess people’s capacity to make decisions and where needed make decisions in people’s best interests. Management and leadership failed to demonstrate they had sufficient knowledge and understanding of their legal requirements.

We were not assured that people always received food at the correct texture to meet their assessed needs and prevent harm. People’s hydrational needs were not always met and there was nothing to demonstrate that appropriate actions had been taken when fluid shortfalls were recorded.

This service scored 25 (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 did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People's needs were not well assessed before moving to the service to ensure people's needs could be met and appropriate care plans implemented in a timely way. We saw a lack of pre-assessment information.

There was little evidence people were involved in contributing to their care needs assessments or developing plans around their care. People's assessments did not always reflect the complexity of their needs, and so did not support staff to meet these needs.

Assessments of people's needs, including risks, their level of need of staff support and assessment of their physical health were not consistently completed and sometimes contained inaccurate or contradictory information.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Recognised tools for assessing risk of malnutrition were not used effectively to identify and monitor risk. For example, although some people were identified as requiring weekly weight monitoring, records highlighted they were being weighed monthly. This meant unexplained weight loss would go undetected causing delays in action or referrals to external professionals if required.

There was no effective monitoring of people’s hydration needs, including actions to take when a person’s fluid intake was inadequate. We reviewed the fluid records for an 86 day period from 1 February to 27 April 2025 and identified that people were not always being offered and provided fluid that they had been assessed as requiring. There were no detailed records providing guidance to staff about the risks of dehydration.
 

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

People were not supported to access dental services. We saw people's care plans lacked information about dentistry services and some stated that their last dental visit was "unknown": despite having lived at the service for 3 years. One person told us they had been told the service did not support them to access the dentist but that they were not able to organise or attend the dentist alone. They told us their teeth hurt, and they would like to see a dentist.

There was a lack of information where care for specific health needs was in place. For example where someone's wound was being treated by district nurses, there was no information on how to position the person's foot. Suitable equipment had not been ordered in a timely way, and the person was at risk of deterioration or prolonged healing of the wound. Another person had very swollen legs which resulted in broken skin.
 

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Although people's health needs were identified, such as those who had diabetes, there was little information about what could be done to best support them to manage this through their lifestyle, such as diet and activity. People did not have goals related to their health, such as target weights if they were over or under weight.

There was little focus on wellbeing. Although we saw some evidence of interaction, staff were not always aware of or responsive to people's mental wellbeing. Clear signs of prolonged distress were not responded to, or recorded to ensure people could have the right support from mental health services or their GP.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Monitoring information was not consistently accurate. This meant people's outcomes were not effectively monitored and escalated where appropriate. For example, people's weights were not always monitored regularly, as indicated by their risks. Although there was some monitoring of wounds to people, including photographs, this was not consistently carried out and the description of wounds and wound care was not always accurate or sufficient to monitor their condition. We were not assured that professionals had appropriate updates to ensure people's treatment was appropriate and effective.

People's pain was not well managed, for example, when people had pain relief prescribed which would help support and maintain their pain levels during mobility and personal hygiene, this was not always administered. This meant people's physical and mental health was more likely to deteriorate.
 

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

Mental capacity assessments were not always completed when decisions were made on people’s behalf. When they were completed, they were not robust and did not always demonstrate how people had been assessed as lacking capacity. Best interest decision making processes were not followed to ensure any decisions made were the least restrictive option. The registered manager acknowledged mental capacity assessments had been completed as a record of why they felt a person did not have capacity after decisions were made. This was not in line with the principles of the Mental Capacity Act 2005.

Consent to care and treatment was not always sought. We saw evidence of consent forms being signed by relatives who did not have the legal authority to do so.