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

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last assessment the provider had not shared their vision and strategy with staff, and their policies were not easily accessible. In this assessment, whilst some progress had been made, further work was needed to embed these improvements. A new manager had started just before this assessment and was still getting to know the provider and the provider’s expectations. However, regular staff meetings were now taking place, and staff were accessing the policies and procedures.

Operational leadership did not always result in effective management or good governance of the service. This service had been without a registered manager since July 2024. It is a condition for this service to have a registered manager. This affected the consistency of leadership and governance. Although the provider managed the service day to day and a manager from another location had been splitting their time between two services. This resulted in reduced management oversight. Whilst we have seen some improvement at this assessment, the lack of consistent leadership had been a barrier to some areas of improvement. For example, some care planning documentation continued to be of a poor quality, the wound care policy was not being followed, and clinical supervision for the nurses was not taking place.

In the last assessment there was no registered manager in place, communication between the provider and staff needed improvement and morale was low in the service. In this assessment a manager had been recruited they told us they were applying with the CQC to become the registered manager for this service. Team meetings and staff supervision had taken place regularly. And staff morale had improved.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

In the last assessment the provider had not created opportunities for staff to speak up. In this assessment we found staff had regular supervisions and team meetings and were given the opportunity to feedback to the provider.

The manager said they had an open-door policy and had recently introduced a staff communication book and staff suggestion box. Staff told us the provider was listening to them.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider told us they made reasonable adjustments to staff work pattern support staff where needed. We saw anarea was available for staff to pray if they wished. Staff felt supported by the provider and did not raise any concerns about equality, diversity and inclusion in the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

In our last assessment, we found shortfalls incare planning documentation, in the recording and reporting safeguarding incidents to the appropriate authorities, and ensuring staff had the necessary skills and support to provide safe care.

In this assessment, we found although audits were being completed regularly, the audits of care plans and risk assessments were not always effective. They did not consistently identify the shortfalls we found during this assessment.

However, we also saw that improvements had been made. A new manager had been appointed and was in the process of registering with the CQC. Staff supervision, training and competency checks were now taking place. Safeguarding records, incident reporting and investigation had improved.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

In the last assessment the provider had not demonstrated consistent collaboration with others. In this assessment, we saw evidence this had improved and that the provider was now working in partnership with others to strengthen the service. For example, the provider has been working with the local authority quality team.

Health and social care partners spoke positively about the service. One visiting professional said staff are responsive and knowledgeable. They told us, staff raised health concerns in a timely way and that health monitoring records were provided when needed.

Relatives confirmed the service worked well with other health professionals including the General Practitioner (GP), district nurses and made appointments with opticians andchiropodists. This partnership approach meant people were supported to access appropriate healthcare in a timely and coordinated way.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They had not always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They had not actively contributed to safe, effective practice and research.

In the last assessment nursing staff were not having clinical supervision. Clinical supervision is a formal process of professional support, reflection and learning that fosters individual development and contributes to improved care for people.In this assessment, we found that clinical supervision still had not taken place. However, the new manager was aware of this gap and told us they were taking steps to understand how to best introduce and support clinical supervision for nursing staff. Nursing staff said although they were not yet receiving formal clinical supervision, the new manager had provided supervision sessions and arranged study days to support them in their roles.

Since the last assessment the provider had introduced a system to collect feedback from people using the service and their relatives. This meant the provider had clearer systems to understand people’s experiences and to use this information to inform service development. However, this had not yet been fully embedded, so it was too early to assess its impact.

In our last assessment, the provider had not held regular team meetings to share learning or to gather ideas for improvement from staff. Accident and incidents had not been thoroughly investigated, and there were no effective systems for people, relatives, or staff to provide feedback that could support improvement.

In this assessment, we found improvements had been made. Team meetings and staff supervisions were now taking place regularly, and staff were given opportunities to feedback.

Staff told us the provider was now more open to ideas for improvement. One staff member, for example, told us they suggested introducing a ‘treat trolley’ for people. They said, “The provider listened to my idea, gave me a budget and now this is in place.”

Processes for reviewing and investigating accidents and incidents had also improved. Incidents were now discussed in team meetings and supervisions to support learning and prevent recurrence.