Archived: The Moorings Retirement Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

We assessed 7 quality statements within this key question.

The provider did not demonstrate how they considered best practice guidance for people with dementia.

People were not supported to plan for important life changes, ensuring they had enough time to make informed decisions about their future, including at the end of their life.

This service scored 39 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The provider’s processes to ensure people received person centred care were not effective. People’s care plans were very brief and lacked relevant person centred information about their preferences and the specific support they needed from staff. For example, some people's care records did not provide information about likes and dislikes other than in relation to food and fluid. There was no information about peoples’ past history, interests and hobbies, no information about what people could and couldn’t do for themselves to maintain a level of independence within their capabilities, how they would like to receive care and preferences in relation to times of getting up and going to bed.

People's care plans did not always contain information that was up to date and did not reflect their current needs.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

The provider did not ensure that referrals to dentist at home service had been requested when required. Not all people had an oral health care plans in place to give guidance and support to staff in the event of a referral needing to be made.

When people had become unwell or been admitted to hospital relatives were not always informed as it happened, meaning people did not have the option of having a loved one accompany them during stressful situations. Feedback we received from relatives was mixed and included, “There have been a couple of occasions, particularly at weekends, where my [loved one] was admitted to the hospital. But I was only informed on the Monday morning by the Manager. I am told when hospital admissions are required at weekends that they are too busy to call anyone”, “I found out from the hospital [loved one] had been there [hospital] several days already, I rang the Care home who were very profuse in their apologies as in not letting me know. It has not happened since,” “Yes, but the one instance (a minor incident) was after 3-4 days,” and “To be honest [loved one] has been in and out of hospital half a dozen times. They always keep us really informed.”

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Care records provided information about what people's communication requirements were and any additional equipment such as hearing aids that may be required. However, we observed people who were not always wearing glasses or hearing aids - despite their care plan highlighting that these were necessary.
We made observations of a person with visibly unclean ears around their hearing aid. Dirty ears especially wax could block and impact on the effectiveness of the hearing aid and the person's ability to hear correctly.

There was written information displayed about how to complain should the need arise. Relatives told us they felt able to raise issues with the management team. There was a complaints policy and procedure in place.
 

The provider did not always make it easy for people to share feedback and ideas, about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The records we reviewed did not demonstrate the people were included in reviews around their care. The registered manager told us, "We are not really involving people hugely".

A residents meeting that took place in March 2025 demonstrated that people were given the opportunity to speak up. However, we were not assured that actions discussed at the meeting had been listened to and actioned. For example, a person raised the lack of activities at the weekend, another person agreed and stated that the evenings were long without activities being provided. We reviewed the activities records which demonstrated that activities had not been implemented at the weekends.

A person stated that the staff, “do a good job” however, they felt that “staff were not given enough time for personal care, meals and always seem under pressure and having to rush”. However, there was no evidence to demonstrate that people’s feedback had been acted upon and during our visits we observed staff were rushed.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it.

People’s needs, including their protected characteristics, such as age and disability, were not considered and were impacting people’s access to services. Where people had a disability which impacted their ability to contact health services or access health, care or wellbeing support outside of the home or into the home if they were unable to leave, people were not consistently supported to have equitable access.

Barriers to accessing health and care services were not considered, and those with higher needs were negatively impacted as a result. People living with dementia had less access to activities and stimulation in the home, as well as access to the community outside of the home. There was limited evidence of how these people were supported to reduce the risk of social isolation.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider had not considered or implemented all relevant best practice guidance for dementia friendly care environments, including ensuring that signage was accessible and that information displayed at the service was clear. For example, corridors were long and there was no clear dementia friendly signage to support people to orientate around the environment. During our visit on Monday 28 April 2025 the information board in the hallway for people was showing the date as Friday 25 April 2025. The menu's on the table were displaying the meal for Thursday. This meant people were not supported to maintain their independence due to the lack of clear dementia friendly signage.

There were no tools in place (such as display plates) to support people with dementia to make dietary and nutritional choices. This meant people were not supported to maintain their independence of choice and impacted their ability to effectively communicate their choices.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

There was no information or guidance to support staff delivering end of life care and to ensure that people’s wishes during the final stages of their life were carried out and respected.

People’s end of life care plans were basic and did not contain person centred and accurate information, The care plans were generic and consisted of copied and pasted information across several people's care plans. Detail of involvement of family and friends for some people was incorrectly recorded. For example, a person's end of life plan stated that their daughter to be informed, however, this person did not have any immediate family. Another person's record described staff discussing with my daughter regarding my wishes and funeral directors, burial, or cremation when the time is appropriate, however, this person had sons.

Advanced decisions around people’s care were not recorded clearly and some care records contained contradictory information about people’s wishes. For example, we saw a person’s care record where they had a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) in place. The care plan described they had a DNACPR in place and were not to be resuscitated, however, due to the copy and pasted information in care plans it described another person’s name where staff were required to attempt resuscitation. This meant staff would not have the correct and up to date information to ensure a person’s wishes were respected.