Moorhead Rest Home

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• 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 requires improvement. At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulations in relation to providing safe care and treatment and the governance of the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. While some people and relatives knew about care plans, not everyone had seen them or hadn’t been involved in reviewing care plans for some time. We saw little evidence to suggest people had been involved in a review of their care needs. Care plans held conflicting information which meant staff may not always know how to provide the appropriate care and treatment for people. We saw some evidence of initial assessments, however, not everyone had this in place.

Staff told us, “Care plans are on the electronic system. The deputy updates them and I have had time to read them.”

The service did not plan and deliver people’s care and treatment with them, including what was important and mattered to them. Nutritional plans were in place, however, where guidance was in place such as a person to be weighed weekly, this was not always taking place. Where nutrition risk assessments advised of monitoring diet and fluids or for referrals to be made to other healthcare professionals, there was no evidence this had been done. This meant people were at risk of weight loss. Staff including the chef had not completed training in relation to food safety awareness or diabetes, despite several people living at this service with a diagnosis of diabetes. This meant we could not be assured people were being cared for appropriately and that staff were aware of how to manage this condition.

People and staff felt the food was of a good standard and that people were supported at mealtimes. One person said, “The food is good, and we get plenty to eat, if you don’t like it, they will bring you something else.”

The service worked well across the staff team to ensure important information was passed on. Handovers were taking place daily to ensure all staff were kept up to date about people’s needs. Staff told us they worked well together and that they were informed of any changes through regular handovers.

Relatives told us staff worked well together and appropriate referrals would be made when needed. One relative said when asked if the staff work as a team, “Yes, they do, they are quite together with no backbiting. They are long term staff and they get on and they have a laugh with [person.]”

The service did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. The service did not support people to live healthier lives, or where possible, reduce their future needs for care and support. Risk assessments relating to people’s specific health conditions were not in place. For example, people who had a diagnosis of diabetes or COPD (Chronic Obstructive Pulmonary Disease) did not have plans in place to guide staff about the action to take should the persons condition deteriorate. There was little evidence in people’s care records to suggest what input the person had from healthcare professionals and where assessments indicated the need for a referral, there was no evidence this had been done.

We were not assured people were receiving oral care as documented in the person’s care plan as we found toothbrushes were missing in some bedrooms and staff gave a contradictory account to what was written in person’s care records. Despite multiple requests for professionals contact details to obtain feedback, these were not provided. Whilst on site we were able to speak with one professional who raised no concerns. People told us they could access a GP should they need to.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. Tools for monitoring outcomes were not robust. Risk assessments were not always accurate, and audits/analysis were not always completed to mitigate risks and improve future outcomes. We received mixed feedback from staff in relation to having time to sit and talk to people. Some staff felt there was time whilst others felt care was at times rushed due to low staffing levels.

People told us they felt supported to lead healthy lives. One person said, “They (staff) encourage me to walk with my frame to get around.”

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. We saw evidence of consent forms for various areas and evidence these had been signed by the person or their relative. Staff told us they always ask for consent before delivering care.