Archived: The Moorings Retirement 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

We assessed 8 quality statements within this key question. We identified 5 breaches of the Regulations. People did not receive safe care which met their needs. Safeguarding incidents were not consistently recognised, or action taken to prevent further abuse. We also identified concerns regarding staffing, fit and proper persons employed; and premises and equipment.

The providers safeguarding processes and systems were not effective, such that we were not assured that the risk of avoidable harm to people had been appropriately mitigated. Risks to people’s health, safety and wellbeing had not always been identified. Guidance for staff on how to avoid risk was either unavailable, contradictory, incorrect or insufficient.

People’s needs had not been fully assessed. Guidance for staff was not always clear or consistent and failed to contain sufficient detail to enable staff to meet their needs. There was a lack of routine monitoring of peoples’ care and treatment to achieve positive outcomes. This placed people at risk of harm.

Nationally recognised assessment tools were in place but these were not always being completed correctly or effectively to mitigate risks to people.

The provider did not ensure people were supported by staff who had the relevant skills, knowledge and training to meet their needs. The providers recruitment practices were not in line with requirements to ensure they followed safe recruitment processes when new staff were employed. Premises and equipment were not always maintained.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider failed to ensure that incidents and accidents were consistently identified, investigated and learned from.

Although incident audits showed the number of incidents in which each person had been involved, there was no further information to include analyses of trends, the quality of recording and confirmation that appropriate action had been taken. For example, ensuring that the correct agencies had been informed.

Letters informing people’s relatives about incidents consisted mostly of copy and pasted information from the actual incident report. However, this did not always include or reflect the full detail of the incident which meant that relatives were not always receiving the full information.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The provider did not have a robust and safe system in place to ensure that people’s care records contained sufficient guidance for staff to follow. We found there was a lack of clear, timely and consistent information about people's health needs where they may be receiving care from different services, such as the district nursing team.

There was a lack of information on people's usual presentation or physical observations, which meant signs of ill health could be missed. Staff lacked a shared understanding of signs of illness or where care needs required escalation to other healthcare professionals. For example, while at the service we observed several people were coughing. Some were on antibiotics, however one person, who had a wet sounding cough, was told by staff it was, "Probably hay fever." This was not escalated to senior staff to seek appropriate medical advice.

Care records did not identify people's current needs, meaning information could not be easily provided to other professionals or hospital should the person be admitted. For example, one person had a pressure injury to their heel, with no information in the care plan about this, or how it was being managed.

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.

The provider failed to identify and notify the relevant agents about potential safeguarding incidents. We identified several incidents that met the threshold for a safeguarding referral as well as being notifiable to CQC, however, the management had failed to complete these.

Observations throughout our assessment identified neglect through the omissions of care. This included the lack of hand care for a person who had a tight hand contracture, the lack of pain relief offered and administered; and the lack of timely onward referrals. For example, due to the discolouration and offensive odour, we made a request to a visiting healthcare professional to remove a rolled up piece of gauze found in a person’s tightly contractured hand. When we reviewed personal care charts we identified 24 gaps in hand care over a 59 day period. The management team were unable to tell us how long the gauze had been in place. Care plans described a specific hand support was required however, this was not observed to be in use. Management told us that this had not been used since August 2024 as they were unable to put it on. The provider failed to make an appropriate onward referral to ensure that the person received the correct support from August 2024 until we raised the concern in May 2025.

The provider did not ensure people who were prescribed pain relief were offered and administered this pain relief through periods where it would be required. For example, the inspectors requested pain relief be given for a person who was in pain due to a pressure injury. On review of the person’s medicine records it was identified that pain relief could be prescribed up to three times a day, however, out of 104 possible doses that the person could be prescribed, staff had only administered pain relief on 9 occasions.

During this inspection we identified concerns that leaders of the service did not always ensure people were appropriately protected from avoidable risk of harm and neglect. For example, staff did not always respond appropriately to people whose behaviours may challenge due to distress and agitation. We identified a minimum of 5 incidents that explicitly recorded the use of physical intervention and restraint. For example, a person who had been assessed as a high risk of falls due to a complex medical condition had been displaying agitation. Records recorded that staff had removed the persons walking stick. This placed the person at further risk of falls. Another record described, ‘We had to hold their hands whilst other [staff member] washed them, it took us two to wash and dress them.’

We saw some evidence of Deprivation of Liberty Safeguards (DoLS) conditions being complied with. However, DoLS applications did not always contain relevant and up to date information. For example, they did not account for situations where people expressly asked to leave or behaviour such as attempting to open doors or spending all day sitting by the front door which implied their wish to leave.

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

We were not assured that risks to people were assessed and safely managed. These included risks related to falls, moving handling, repositioning, wound management, food textures, bedrails, catheter care and risks associated with specific medical conditions.

People with complex health conditions such as Epilepsy and Parkinson’s disease, did not have care plans containing sufficient detailed information to guide staff to identify deteriorating health triggers and what actions to take.

We found poor management of risks to prevent damage to people’s skin. We saw shortfalls in people’s repositioning records that demonstrated people were not being repositioned in the timeframe they had been assessed as being required to maintain their skin integrity. A person with a pressure injury had their foot inappropriately placed on a foot stool which placed them at risk of further pressure damage.

Catheter care was not well managed. We reviewed records for a person who had a catheter and noted a requirement for staff to ‘to empty and monitor [person’s] catheter’ and ‘to check urinary output’. However, over a 28-day period there were gaps noted in urine output on 17 days. This ineffective monitoring placed the person at increased risk of complications impacting their health and well-being. .

Risks of injury from the use of bed rails (including entrapment which can result in suffocation or injury) were not effectively assessed and managed appropriately.

We observed instances of unsafe moving and handling techniques. An inspector had to halt a hoisting procedure due to a person becoming distressed and in pain and we noted the person’s care record did not reference a hoist being used. Management told us that no external referral had been made and they completed the hoist assessment. When asked how the assessment of the sling size was determined, they told us “We tried a medium and it fit”. From our observations all the hoist slings we checked were the same size (Medium).

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We identified significant shortfalls in the safe management of the environment. There was an absence of appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected. This increased the risks to people’s immediate safety and was demonstrated through the concerns highlighted with environmental risks which included, but were not limited to, the poor state of cleanliness, fire safety and water safety.

The provider had not taken action to minimise environmental risks of injury. The provider failed to ensure that all items of heavy furniture were appropriately and safely secured to the wall. Tamper proof window restrictors were not in place on all windows including bedrooms and areas on the 2nd, 3rd and 4th floor. Windows fitted with initial opening restrictors did not comply with the Health and Safety Executive guidance on health and safety in care homes and were not suitable in social care premises where individuals are at risk, as they can be easily overridden. Bedrails and bumpers were not fitted in line with health and safety requirements, placing people at risk of entrapment.

The provider lacked effective system to manage risks associated with a bacterium called Legionella which can proliferate in building water systems. We noted a lack of oversight of water temperatures and of an awareness of actions to take when they were outside the safe ranges.

Fire safety was not well managed and fire safety checks were ineffective in identifying the concerns we found on this inspection. For example, we observed fire doors that led onto escape corridors were blocked with chairs or wedged open. The fire risk assessment dated 12 February 2025 described a staff member as, ‘Providing bespoke training for staff’ but provider records could not confirm they had been trained to deliver this training. Records failed to demonstrate that fire drills were simulated to ensure staff were adequately prepared in the event of a fire.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The providers systems and processes in place to ensure the safe recruitment of staff were not effective. We found the pre-employment checks were not carried out in line with requirements. This included the lack of pre-employment checks in relation to obtaining satisfactory evidence of conduct in previous employment concerned with the provision of services relating to health or social care, or children or vulnerable adults; and satisfactory verification of the reason why the person’s employment in that position ended. This meant people were at risk of receiving care from staff that had not been proven to be of good character.

Staff were not adequately trained and the providers training matrix did not provide accurate information. Where staff required training or refresher training this was not always identified on the training matrix in line with the service’s policy. The registered manager undertook staff competencies and face to face training for manual handling, however they were unable to demonstrate they had received the appropriate training to carry this out. The provider’s records identified that staff did not receive supervision and appraisals in line with their policy.

We were not assured staffing levels were safe or sufficient to meet people’s physical and mental health needs. Dependency tools (which help the provider judge the number of staff needed and are based on people’s needs) had not assessed people in line with their current needs or level of dependency.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider failed to ensure that the environment and equipment were clean. During our site visits we identified there was a constant smell of urine in the hallway, at the entrance of the home. However, this had not been identified during the management’s Infection Prevention Control audit. We identified that people’s wheelchairs, stand aids and slings were being shared, and were not being cleaned between use. We noted that people's stored wheelchairs were dirty and one smelt strongly of urine.

There were areas in the home that had exposed wood, this included shelves in communal rooms and hallways, tables and chairs. Soft furnishings were not always in a good state of repair (for example some chairs and cushions had areas of exposed foam). Some wheelchairs and trolleys had rusted and corroded surfaces. Exposed wood, exposed foam and areas of rust on equipment increased the risk of infections spreading due to these surfaces being difficult to effectively clean.

Control of Substances Hazardous to Health (COSHH) restricted products were not always stored safely. COSHH regulations are aimed at protecting workers from health risks associated with hazardous substances in the workplace. We found a cupboard containing COSHH products to be unlocked. Also, although COSHH products had data sheets in place, these products did not always have a detailed risk assessment and the risk to people was not considered.

The majority of staff had not received IPC training in the last year, which was not in line with the service’s IPC policy.

People’s laundry was not kept separate from other people's during washing or drying which increased the risk of cross contamination of infections from one person to another.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst lockable medicines trolleys, Controlled Drugs (CD) safe and medicines fridge were within a lockable medicines room, during our inspection the inspection team were able to access the medicines including the CDs. Therefore we were not assured that medicines were stored safely and securely.

Room and fridge temperature records provided assurance that medicines were kept within their recommended temperature ranges. CD records were also complete. Staff explained the process for finding additional information about medicines. However, we noted that out of date paper reference books and folders were also available to staff. Whilst staff told us the out of date references would be removed, we observed these remained in place on our 3 visits to the home.

We noted that ‘When required’ medications protocols contained some personalised and individualised information, however, there was scope for these to be developed further especially where multiple medicines were prescribed for a medical condition (for example constipation). We noted that ‘Variable dose’ protocols were not available to support staff to ensure people received the right dose when variable doses were prescribed.