Moorhead Rest 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 inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service.

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 service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Staff had mixed views on the culture of this service. While some staff felt the culture had improved, others felt it was not a positive environment. Staff raised concerns about the management team and felt they were not always listened to or consulted when decisions were made. Staff also spoke of cutbacks being made which effected people’s wellbeing including activities and staffing levels.

Staff meetings were not taking place regularly or when there had been a change in management and staff told us they had not attended a meeting for some time.

The service 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 manager was very new to the service at the time of the assessment, however, staff had concerns about the leaders of this service overall. Staff were not always confident in who to approach should they have any concerns and staff felt they were at times shouted at rather than listened to. While some staff could see improvements made, others did not feel supported in their role. One staff member said, “We have another new manager. The owner hardly visits, we don’t always know who to go to if we have concerns.” However, staff did praise the new manager. One staff member said, “The new manager is approachable and is easy to speak to.”

There have been several changes of management since the last assessment and there has been no registered manager for some time at this service. There was little evidence of an induction process taking place for the manager. Most of the concerns found at this assessment were present at the last assessment and there has been no sustainable change.

Staff did not always feel they could speak up and that their voice would be heard as they did not always know who the best person was to speak to. Staff told us they knew the whistleblowing process; however, concerns were raised in relation to providing feedback. One staff member said, “Not had any staff meetings recently. I did a feedback form a while ago, but the manager filled the form for me, I didn’t get a say.”

The service valued diversity in their workforce, however, not all staff had completed training in equality and diversity. Staff told us they were treated fairly and the manager told us reasonable adjustments were in place for staff such as adapted workstations, flexible hours and assistive technology.

The service 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. There was a clear lack of oversight into the governance systems at this service and a lack of effective audits taking place to ensure good governance. No provider audits were taking place despite there not being a registered manager at this service for some time. This issue was found at the last assessment and no action had been taken. The CQC rating was not displayed on day 1 and day 3 of the site visit despite requests for this to be displayed. There was a lack of oversight into people’s care records and the leaders of this service contradicted some parts of people’s care plans.

Policies and procedures were not reflective of the current situation. Some policies held details of the previous manager and nominated individual, and some policies were not being followed. Staff told us they were not confident in the leadership of this service.

We requested a provider action plan following our assessment. What we received was basic and held little information on what improvements would be made. We also requested documents numerous times during our site visit and after our site visit, not all of these were provided. We did not receive assurances that changes would be made to ensure effective governance of this service.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We saw limited evidence of partnership working in people’s care records and despite multiple requests for professional contact details to obtain feedback, these were not provided.

People told us they weren’t supported into the community unless their relatives took them out. Staff told us of one occasion whereby a person became distressed and staff used their own money to take the person out as the service would not allow for this.

The service 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. They did not actively contribute to safe, effective practice and research. There was limited evidence that feedback from the last assessment had been taken on board and despite the provider organising a mock inspection before our visit, no action had been taken to rectify concerns found. Lessons learnt evidence was minimal, however, the manager was in the process of implementing stronger systems to ensure continuous learning was in place.

The manager told us information and learning were shared with staff and other professionals to try and improve the service. However, we saw no evidence of this.