Moorhead Rest Home

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• 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 changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff praised the service and the new improvements and felt staff morale was high. Staff comments included, “There is a good culture. (The provider) comes in and speaks to staff and is always there to talk to. I absolutely adore working here, it is my second home. I adore all the people here; we all have a good relationship. We have a house cat who is also part of the family. The residents love the cat. It is like pet therapy” and “It is a lot better here now. It has improved so much. The environment and staff morale are much better.”

The registered manager carried out spot checks at different times of the day and night to ensure the service and staff were working in line with the services values. The registered manager said, “Our service is guided by values of dignity, respect and person-centred care. Strategic goals focus on continuous improvement.”

Not all leaders understood the context in which the service delivered care, treatment and support. The registered manager lacked some insight into the running of the service and could not share important information including which agency staff had been working and whether their training was up to date. We were referred to the acting deputy manager for a lot of our queries. Not all information was available on the day of the site visit, and we had to wait for some records to be sent electronically.

Staff meetings were taking place, and staff were completing feedback forms. However, it was not clear what action had been taken when concerns had been raised. Staff raised concerns that the staff surveys were not anonymous therefore staff may not always feel comfortable in expressing concerns they may have. A range of policies were in place. However, not all policies were detailed enough to guide staff. Staff did however praise the registered manager and one staff member said, “(Registered) manager is approachable and has the knowledge and experience to manage the team. If I had concerns the (registered) manager would address them.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident in speaking up should they have any concerns. They said, “I am aware of the term freedom to speak up and I am confident in raising concerns should I need to. Regular staff meetings discuss safeguarding concerns and lessons learnt.” The registered manager said, “We promote transparency through open communication, regular meetings, and a no-blame culture. Whistleblowing policies are in place and staff feel confident raising concerns.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were treated well and one staff member spoke of a time when they had asked for working adjustments and this transition was handled well. Their comments included, “If I had to ask for something, they (management team) would try their best to help.” The registered manager spoke of reasonable adjustments. They said, “We support staff with disabilities through reasonable adjustments ensuring they can work safely and effectively.” Policies for equality and diversity were in place, and staff had completed training in this area. v

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. Some of the concerns identified at this assessment were present at the previous assessment. There was no analysis of incidents, accidents and behavioural events to help reduce future risks. This placed people at risk of harm. Recruitment files had not been audited or risk assessed meaning we were not assured all staff were safe to work at this service. Safeguarding incidents had not been analysed to identify patterns or trends and lessons learnt processes were not always robust. Again, this placed people at risk of harm through ineffective governance processes. Not all audits were robust. Some audits were more of a tick box exercise rather than an analysis of findings. Provider audits were being carried out and were detailed. However, where concerns had been identified, it was not clear what action had been taken as a result. Some records were not accurate and held out of date information including the service user guide and the statement of purpose.

Staff found the registered manager and the provider approachable and said they received support during working hours and on call arrangements were in place.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement. People and their relatives told us they could see improvements within the service. One relative said, “The home has been so much better and more responsive since (registered manager) took over. [Person] has come to the next stage in their Alzheimer’s and as such they recently had a medication change. [Person] used to be a great eater they enjoy their food, but they are forgetting to eat. Now the staff sit with them and will prompt them to eat.”

Staff told us people enjoyed sitting outside in the warm weather, but no-one was supported by staff into the community, and this activity was provided by relatives.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. We saw some evidence of lessons learnt procedures, however for people who were at high risk of falls or of distressed behaviours, it was not clear how this information was relayed to staff or risk assessed to help reduce future risks. Some of the concerns found at this assessment were present at the last assessment and although the registered manager acted on our concerns, we were not assured practices were fully embedded to achieve long term outcomes.

Handover records were detailed and provided information on how well a person ate and drank that day as well as any medical appointments. Staff were allocated champions in various roles of intertest including dementia and infection prevention and control. The role of a champion was to attend additional training and cascade information back to other members of the staff team. One staff member said, “(For activities) we ask people what they like, what they enjoy. We make Easter crafts, chocolate nests and baking.” The service had an action plan on how they could improve systems and processes as well as the environment. It was evident improvements had been made in some areas.