Archived: The Moorings Retirement Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We assessed 7 quality statements within this key question. We identified 2 breaches of Regulation in relation to good governance and a failure to notify CQC of incidents affecting the health, safety and welfare of people using the service.

There was a poor culture at the service. Staff were not consistently supported to develop their knowledge and understanding of people, to discuss a shared vision or to improve people's lived experiences. Staff did not understand the language used within people’s care plans was sometimes disrespectful and outdated. The service was not being managed well and governance systems in place were not effective and failed to recognise the shortfalls in people’s care and the service. Governance arrangements were not always effective (for example regarding quality improvement, safety and risk management).

The provider failed to ensure they informed Care Quality Commission of notifiable events at the service where they are legally required to do so.

This service scored 29 (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 clear shared vision and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Due to the concerns identified on this inspection, we were not assured that the values were embedded into staff practice. They did not understand the challenges and the needs of people and their communities

Whilst we observed some positive role modelling from some of the leaders, there was not a consistent standard of care from the staff team. Staff did not demonstrate positive values in how they treated people or each other.

Staff used inappropriate language to describe people such as “[Person] smells so bad because of wet pad and poo so we have to changed [person].” This can create a culture where people are viewed as a set of tasks rather than individuals. This had not been challenged by leaders.

Systems in place had not identified that some staff training had not equipped staff with the necessary skills to provide person centred care. For example, we observed on numerous occasions people requiring hoisting. However, staff were observed using incorrect techniques which impacted on people’s privacy and dignity. The staff received practical training for the use of the hoist from the registered manager but they were unable to demonstrate that they had the appropriate training to deliver this training to staff.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The management had not always reported safeguarding incidents to external partners responsible for investigating. This resulted in a lack of external oversight and created the risk of a closed culture.

The management had not fully met duty of candour best practice where incidents and accidents had taken place. Whilst we did see letters informing people’s relatives, these did not always reflect the full details of the incident. We were not assured that the management were fully open and transparent with people, their carers or their families when things went wrong.

People did not feel they could speak up and that their voice would be heard.

The providers freedom to speak up policy did not contain the contact details for the referenced freedom to speak up guardian. The freedom to speak up guardian is a person who supports an individual staff to speak up freely when they feel they cannot do so through regular channels. Therefore, we were not assured the provider’s policies and procedures were robust in providing staff the support and information they needed.

Also, we could not be assured staff were given opportunities to speak up due to the shortfalls we identified in relation to formal supervisions sessions. We were not assured that leaders actively promoted staff empowerment to drive improvements. We made attempts to speak with the staff (including by seeking the assistance of the management team) but our attempts were unsuccessful.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Although there was a diverse workforce employed at the service, we found the culture was discriminatory towards staff who were employed from overseas on a sponsorship licence. Staff rotas highlighted that overseas workers worked 12-hour shifts, a mixture of days and nights for over 7 days without having a day off. This included being required to work when the service needed additional staff. We noted that other staff members were not subject to this working pattern.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found significant shortfalls in the providers systems, processes and oversight of service delivery. Management failed to implement robust systems to review and improve quality and safety.

Systems and processes failed to ensure people’s records were always up to date, complete or contemporaneous. We found multiple examples where people’s care records were incomplete or lacked sufficiently detail to guide staff in providing person centred care (for example regarding managing peoples’ specific needs or conditions). Personal care records did not provide assurance that people’s needs were adequately met or provided in line with their preferences.

Systems and processes in place to gain people’s consent and make decisions were ineffective and did not demonstrate care was always provided in line with legal frameworks.

Processes for ensuring staff were suitably skilled and competent were not effective. Systems and processes related to staff recruitment failed to ensure practices were in line with legal requirements.

The provider’s audits did not include effective oversight of all relevant best practice guidance. For example, audits completed did not consider relevant dementia friendly guidance or ensure this was appropriately implemented.

The provider’s governance arrangements had also failed to act on risks we identified (for example regarding fire safety doors, fire safety training, Infection control, bedrails and CCTV).

The provider also failed to notify the CQC of relevant safety events that occurred at the service; and failed to notify the local authority of relevant required safeguarding information.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There was a lack of engagement into the local community to engage and support peoples emotional and spiritual needs.

The management team told us that they sought medical advice and support from health and social care professionals when people’s needs changed. However, we saw examples where this had not occurred. For example, we identified a lack of timely referrals made to external professionals. This included occupational therapists for 2 people and a failure to seek medical advice when peoples’ physical observations, such as blood pressure and oxygen saturations deteriorated outside the normal range.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There was no evidence to demonstrate that lessons were learnt from incidents and when things went wrong to drive improvements in the service. Auditing arrangements were either absent or not robust enough to drive quality and safety improvements.

There was no clear plan as to how best practice and up to date guidance would be incorporated into the running of the service. For example dementia friendly guidance and activities.