Moorhead Rest Home

Updated 14 May 2025

Moorhead Rest Home is a residential care home which provides accommodation and personal care for up 27 adults living with a dementia, physical disabilities and sensory impairments. We assessed all quality statements under the five key questions of Safe, Effective, Caring, Responsive and Well Led. We undertook on-site visits on 16 and 17 June and 1 July 2025.

At our last assessment we identified breaches in legal regulations in relation to safe care and treatment, good governance, staffing, recruitment, premises and equipment and consent. At this assessment the service was no longer in breach of the legal requirement consent. However, we found continued breaches in safe care and treatment, good governance, staffing, recruitment and premises and equipment.

We found a lack of oversight in the analysis of trends and themes, and we were not assured measures were in place to reduce future risks when safety incidents occurred. People were not always safe and protected from harm and staff did not have knowledge of DoLS (Deprivation of Liberty Safeguards). Risks to people were not managed well and risk assessments were not always accurate. The environment people lived in was not safe and fire safety concerns were not always addressed. Staff were not recruited safely and concerns were identified in staffing levels. Staff were not receiving regular supervision and staff training was not up to date. We found concerns relating to the infection, prevention and control of this service and unpleasant odours were identified during our site visit. Medicines were not always being managed safely and staff who were trained in the administration of medicines didn’t all have an up to date competency assessment in place.

We found little evidence to suggest people had been involved in the care planning process and little evidence referrals had been made to the relevant healthcare professionals. Risk assessments were not in place for people with a specific health condition and we found records contradictory. Staff told us they didn’t always have the time to sit and talk to people.

People’s personal information was not always protected as we found confidential information was not secured. The environment was not secure and there was limited signage in place which could make the environment confusing for some people. People’s advanced wishes had not been taken into consideration and there was a lack of training in this area.

Staff did not feel supported by the leaders of this service and staff told us morale was low. Staff were not confident in who they should approach should they have any concerns and there had been no registered manager at this service for some time. Most of the concerns found at this assessment were present at the last assessment and there was a lack of effective audits and provider audits to ensure good governance systems. Staff were not having regular meetings and were not always kept up to date of any changes. Policies and procedures were in place, but they were not accurate or being followed. We made numerous requests for professional contact details and for various records, some of which were not provided.

Staff felt the service was kept clean and told us they had time to read people’s care plans. Staff felt that as a staff team they worked well together and daily handovers were taking place. Consent was sought when required and the service was following the Accessible Information Standards. Contingency plans were in place as well as on call arrangements.

This service remains 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.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Updated 14 May 2025

Not everyone had seen a copy of their care plan or had been involved in this process. We observed staff did not always treat people with dignity and respect. We observed an incident whereby staff were not communicating well with a person who was distressed and one staff member walked away with their fingers in their ears. We did however, witness other staff members treat people with kindness and patience. Activities were not always being carried out to avoid social isolation and we saw no evidence people had been consulted on how they would like to spend their time. No extra checks were in place to ensure the safety of people who were confined to their bedrooms when the lift had broken down. While some staff felt people were able to make their own choices, other staff raised concerns in this area. One staff member said, “There isn’t really any person-centred care because there isn’t enough staff. So, people have to go to bed when there is more staff here, they don’t have a choice.” However, other staff told us people did have a choice of when they liked to go to bed.

People felt safe using this service and relatives felt people had settled into the service well. One relative said, “It was difficult at first, but [person] has settled in now, the home is a bit dated, but they’re happy there and the staff are lovely.” Relatives told us there was enough staff to ensure people had what they needed. People felt the service was clean. One person said, “They (staff) clean my room every day and the lounge and dining room are kept clean and tidy.” People felt the food was of a good standard and that they would always be offered a choice. Relatives felt staff worked well together and people told us they could access a GP when needed.