Moorhaven Care Home Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems in place to review and investigate accidents, incidents and safeguarding concerns. Staff managed accidents and incidents safely. Systems were in place for recording events, and changes had been implemented in response to lessons learnt. Falls evaluations were completed at the head office.

Analysis of accidents and incidents to spot trends had not always been undertaken. The provider identified this as part of their audit process and an action plan was in progress to drive improvements.

Staff reported an open culture where they were encouraged to report all concerns. They told us, “I’m not worried about anything here. If we have any issues, we report them to [registered manager] and they resolve the issue or escalate it.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed prior to them moving into the service. Information of care needs assessed by the local authority and information from people and their relatives was used to inform people’s initial care plans and risk assessments. A relative told us, “I was involved in the care planning. I speak to staff daily and I am involved in the care reviews.”

Documents known as ‘Hospital Passports’ were in place. These documents are for people to take to hospital with them to help medical staff understand the person, their needs and the support they need to meet them. Hospital passports were reviewed as people’s needs changed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were protected from the risks of abuse and staff were trusted to keep them safe. People told us, “I like it here, it is brilliant, it is home. I feel safe here”, “I love it, it is lovely here. I feel safe” and “I feel safe here. Every day is a blessing here.”

Staff had received training in how to safeguard people. Staff we spoke with were confident to report concerns and satisfied that action would be taken to investigate them. Staff told us, “I would report concerns to [registered manager] and I know I can also go higher and contact the provider” and “I would go to the manager and provider if I had any concerns.”

Staff received training in the Mental Capacity Act 2025 (MCA) and deprivation of people's liberty (DoLS). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Staff understood consent, the principles of decision-making, mental capacity and DoLS. One staff member told us, “MCA is whether someone can make a decision and consent about something.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were assessed and actions were taken to reduce the risk of harm. For example, in relation to falls, choking and skin breakdown. Staff we spoke with were aware of these and understood how to support people safely.

Care plans provided guidance for staff to ensure people received safe and responsive care and support. Risk assessments were person-centred and regularly reviewed.

People and relatives were involved in managing risk and care planning. This was reviewed regularly or when people’s needs changed. A relative told us, “I get updates and I am involved in reviews and [relative’s] care. Staff always ring me [to keep me informed], they are good.”

The provider detected and controlled potential risks in the care environment. However, they did not always make sure equipment, facilities and technology supported the delivery of safe care.

The building and facilities were suitable for the people who used them and were in good condition.Dementia friendly signage and visuals were in the service to meet the needs of the people who lived there.

Compliance checks to ensure the safety of the building, environment and facilities were not always up to date. There were some gaps in maintenance checks, in particular when the service did not have a maintenance staff member at the end of 2025. After the maintenance role was filled the checks had been regularly maintained.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Recruitment checks were robust to ensure staff were suitable to work with vulnerable adults. Staff had the necessary safety checks in place before starting work and completed a full induction. A staff member commented, “I had an induction when I first started, it was good. I did training and shadowing [observing experienced members of staff], it was enough for me. I already had experience [in care] too.”

People told us there were enough staff to meet people’s needs. One person commented, “Staff come quick when I press my buzzer.”

Staff received regular training and competency checks to ensure they were skilled to carry out care tasks. A person told us, “I have a hoist and the carers know what to do.”

Staff had opportunities for supervision [support sessions with their line manager], however, they informed us their supervisions were in group sessions as opposed to 1:1 sessions. Staff also told us appraisals were not always taking place. The provider was aware of this feedback after a recent staff survey and was in the process of implementing an action plan to increase staff 1:1 supervisions and appraisals.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was well maintained and appeared visibly clean with no malodour. People and their relatives told us, “My bedroom is clean and so is the home” and “They [staff] clean my room every day.”

The provider had systems and processes to prevent and control infection. There was guidance and information displayed for staff, cleaning schedules were completed, and infection prevention and control (IPC) audits were regularly undertaken to ensure the cleanliness of the environment and staff competence. Laundry was safely managed, with systems to reduce the risk of cross contamination.

Staff were trained in IPC, and we observed them using personal protective equipment (PPE), such as gloves, masks and aprons, appropriately. A relative told us, “Staff always wear PPE.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always managed safely. One person was receiving covert medicines [the administration of medicines disguised in food or drink] however, there was no mental capacity assessment or best interest decision recorded, and a deprivation of liberty safeguards (DoLS) in relation had not been applied for. A pharmacy had not been consulted around the safe administration of each of their medicines.Temperature checks for the medicine room and the fridge that stored medicines had not been completed consistently. Prescribed thickeners had not been recorded after each administration and the recording process for administering prescribed creams was not robust. This was a breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People received their daily medicines and systems ensured timely administration of medicines. People told us, “The nurses give me my medication and the carers apply my gel every day” and “I get my medication on time, and the carers apply my creams.”

Staff were trained to administer medicines. Staff had to undertake training before they could administer medicines and received competency checks to ensure they administered medicines safely.