Moormead Care Home

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 inspection, this key question was rated as requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.We found continuing breaches of the legal regulations relating to safe care and treatment and staffing.

This service scored 38 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not thoroughly investigate or report incidents. Lessons were not learnt to continually identify and embed good practice.

Accidents and incidents were not thoroughly investigated to learn lessons and embed good practice. Record-keeping did not provide adequate detail about actions taken and outcomes. For example, records of one incident reviewed by the Nominated Individual (NI), where a medicine was missing from the blister pack, did not include steps taken to find out what had happened to the medicine. Records concluded that this was presumed to be a mistake by the pharmacist. Another incident record did not include records of conversations held with staff in relation to an incident they were involved in. Staff were not always reporting incidents that have happened to themselves. For example, a staff member told us they had been involved in an incident and had not reported it. There is a risk the service is not learning from incidents.

Staff meetings had not occurred regularly since July 2024 for learning discussions to take place. However, following our inspection the provider supplied us with evidence of meetings which had been held in August and September 2024, and January and February 2025. Staff told us they were aware of incidents that had happened, and we saw where staff had taken steps to reduce the risk of harm to people by reviewing and updating people’s risk assessments and care plans.

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.

Staff told us they worked well with health and social care professionals and had developed good working relationships.

There were clear processes to ensure people’s current information was safely shared with health and social care professionals. Staff told us they had weekly ward rounds with a health professional from the local GP surgery. Records showed people were reviewed by health professionals when required. A staff member explained they liaise with specialists for eating and drinking and pressure care. They went on to explain when people were nearing their end of life, advice and support was sought from the local hospice.

A relative said their relative’s needs were assessed before they moved into the service. They said ‘I have seen the care plan, and I have signed it off…I also provided a complete list of [relative’s] likes and dislikes.

The provider did not always share concerns quickly and appropriately with relevant authorities. We found accidents and incidents were not investigated thoroughly and safeguarding alerts were not always made.

The provider’s training matrix showed staff had completed safeguarding adult training. However, one staff member could not recall the last time they had completed this. Staff said they would report safeguarding concerns to the nurses.

People we spoke with, and relatives, felt they were safe in the service.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Issues in relation to care planning documentation identified in the last inspection had not been resolved.

Care plans were not stored in one file, were not always stored with risk assessments and were not easy to follow. For example, in one person’s skin integrity care plan it was documented, “Staff to monitor, report and record any concerns to a senior member of staff” and “Staff to ensure regular repositioning happens to prevent skin breakdown." There was no guidance for staff to inform them what to look for and there was no definition of what “regular repositioning” meant. This person had been assessed as at high risk of skin damage, and the care plan made no reference to this. We looked at the repositioning records for this person and although the form had sections for staff to tick the required frequency when repositioning had occurred, this had not been completed. It was therefore difficult to assess if repositioning records reflected care plan guidance. However, the person had not come to harm, and staff confirmed their awareness of skin integrity and were able to explain how often the person was re-positioned. The provider’s own auditing process had not identified these gaps in repositioning recording prior to our inspection.

Care plan guidance around the risk of choking was lacking in appropriate practical detail for staff to follow such as using smaller spoons when eating to encourage smaller mouthfuls and did not include guidance such as avoiding distractions from the TV or radio. However, there was some guidance for staff on how to position people to reduce the risk of choking. Staff were aware of people’s guidance around their meals.

Some people had been assessed as at risk of malnutrition; however, their care plans made no reference to this. Malnutrition risk assessments were filed separately from care plans, and it was unclear how staff would be aware of the risks. However, staff confirmed their awareness of people’s nutritional needs and where to find information. One malnutrition risk assessment had been incorrectly calculated, but this had not been identified by staff or during audits.

People’s weight was monitored. When people had lost weight, records showed staff had escalated concerns to the GP. However, care plans did not always include information for staff such as food preferences, frequency of monitoring people’s weight and any specialist advice sought. When people were having their food and fluid intake monitored, records showed people were provided with regular meals. Care plans referred to people being encouraged “to drink plenty” but did not clarify what ‘plenty’ meant. It was unclear how staff knew about any fluid intake targets, and it was also not clear how concerns about poor fluid intake were noted and escalated. However, we saw people’s dietary needs including diabetes, allergies and dislikes were displayed in the kitchen for staff to be aware of.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

The provider had not completed a suitable and sufficient risk assessment to ensure that control measures were always in place. For example, outstanding actions had not been completed in relation to the service’s fire risk assessment as advised by an external professional. This could put people at risk of harm in the event of a fire.

At the time of the inspection, the provider told us they were reviewing all the risk assessments in relation to the service and there was no risk assessments present in the service for us to review. The provider confirmed they had reviewed all the risk assessments following the inspection visit and sent copies of the risk assessments which the provider confirmed were now held in the service.

However, some processes were in place to check the environment was safe. For example, the provider completed regular audits to check the safety of equipment used in the service. People and their relatives did not raise any concerns about the environment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Supervision had not taken place in line with the provider’s policy which stated, ‘each supervision session should take place every 3 months.’ We looked at supervision records for 5 staff members that had taken place and identified some discussions recorded on the supervision documents around safeguarding, food safety, fire safety and first aid appeared to be the same reply from each staff member. However, some staff said they had not received a supervision since July 2024 and team meetings had not happened for staff to discuss best practice. However, following our inspection the provider supplied us with evidence of meetings which had been held in August and September 2024 and January and February 2025. The provider said they were trying to provide staff supervision in the absence of a registered manager.Nursing staff were not being supported to critically reflect on their practice. We found clinical supervision had not been provided for nursing staff. Clinical supervision is a formal process of professional support, reflection and learning that fosters individual development and contributes to improved patient care. However, nursing staff said they have discussions with each other about their practice to help them reflect, learn and support their professional revalidation with the Nursing Midwifery Council.

Staff had completed training set by the provider. However, following observations undertaken during our onsite visits and in conversations with staff, staff did not demonstrate adequate understanding in relation to swallowing problems

(dysphagia). A staff member said they had not completed this training although the training records said they had. The NI had also not completed their own assurances to check staff competencies. The NI sent us a mealtime observation completed after the first inspection visit. However, we were not assured the NI had the appropriate training to be able to assess staff competencies.

The provider did not have a process in place as outlined in their own Disclosure and Barring Service (DBS) Checks policy to check existing staff do not have any criminal records every 3 years in line with best practice. For example, the last DBS checks for one staff member was in 2004. The NI said they had inherited the staff from the previous provider and had not made the additional checks to assure themselves staff still had no criminal records.

However, staff said there were generally enough staff. Nursing staff said they covered each other’s annual leave and although happy to do this most times, the nurses said they would like alternative cover arrangements to be made available, for example, a bank nurse to prevent staff becoming tired from overwork. There was a risk to people of poor practice and treatment if nurses were tired. There was mixed feedback from people and relatives about staff. Some people and relatives said there were not enough staff available for social interactions and interactions were task-based. However, some people and relatives said there were enough staff in the service. A relative said, “I have never had a problem with staffing levels, and they seem to have consistent staff, which is good for [relative]. There are always staff available.”

The provider assessed and managed the risk of infection.They detected and controlled the risk of it spreading. Personal Protective Equipment, (PPE) for example, disposable gloves and aprons was available to staff and staff were wearing this appropriately. Weekly safety checks, and audits were completed by the provider. Food safety procedures were in place and were followed by staff. Staff had received infection prevention and control training.

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

Care plans for people did not always reflect their individual needs. There were no details included on how people liked their medicines administered. For people receiving high-risk medicines, there was not always an appropriate risk assessment in place. For example, a risk assessment was not in place to explain how to safely support a person who was prescribed blood-thinning medicine. This put the person at risk of harm if they fell. Risk assessments related to prescribed topical paraffin-based emollient creams were also not in place for some people. This could place those people at risk of harm if they were exposed to fire.

Body maps were also not in place for some people to show staff where prescribed topical creams needed to be applied to ensure the consistent application topical creams. Drinks thickener products were not managed correctly in the service. Drinks thickener products can put people with dementia at risk of choking if they are not stored safely. Staff were not aware of the national guidance relating to the administration and storage of thickeners. Thickeners were found in people’s rooms during our onsite visits, and people were without appropriate risk assessments for their use. There were no records of thickener administration in the service to show when this had been administered.

Some medicines, such as pain killers, were prescribed to be used ‘when required’. However, appropriate protocols to support the administration of ‘when required’ medicines were not always in place to support staff to make consistent decisions about when these medicines would be required by people.

Staff told us they received annual e-learning related to medicines. However, CQC found no medicines related competency checks were undertaken by the provider to check staff were administering medicines safely to people.

Medicines errors were not routinely recorded at the service. Staff told us when medicines errors had occurred, there was no process for retraining or learning for the staff involved.There were risks to people’s health and wellbeing if staff are not learning from medicine errors and repeating medicine errors.

There was a medicine policy in place at the service. However, we were not assured staff always followed it. Although monthly medicines audits were being undertaken in the service, these had failed to identify the issues we saw with medicines on inspection.