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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last inspection, this key question was rated as requires improvement. At this inspection, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The provider was in continued breach of the legal regulation in relation to good governance. Systems and processes continued not to be effective in assessing, monitoring and mitigating the risks to health, safety and welfare of people using the service. We found multiple shortfalls in care planning records and processes which had not been identified in the provider’s own audits. The provider had not made improvements in relation to the systems and processes to ensure oversight of staffing and safe care and treatment.Despite some efforts to recruit, a registered manager had not been in place at the service since July 2024.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.The provider’s vision and strategy had not been shared with staff. The service policies and procedures were held electronically, and information about how to access the policies was displayed in the service. However, the NI said staff probably do not access policies and procedures due to their work constraints, but the NI had not considered alternative ways to share information with staff. We were told staff meetings had not been held regularly in the service since July 2024 to share information and update staff. However, following our inspection the provider supplied us with evidence of meetings which had been held in August and September 2024, January and February 2025.

The provider 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. The provider did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.There was no registered manager in place to have good oversight of the service, and the provider did not lead the service effectively. Communication between the provider and staff was poor. Team meetings had not regularly taken place since July 2024. Following our inspection the provider supplied us with evidence of meetings which had been held on August and September 2024, and January and February 2025. Some staff had not received a supervision. Supervision records which had been completed appeared rushed and contained limited information and some records showed the same information between different staff members.

The provider did not always lead with integrity, openness and honesty. For example, potential safeguarding incidents had not been raised with the appropriate authorities.Communication with the provider was difficult to follow and contained discrepancies, for example, emails in relation to the service’s remaining fire risk assessment actions did not provide adequate assurances all appropriate work had been completed and evidenced. The provider said they had not attended any training to support them in their role as a social care provider for a while; however, they said they regularly received emails from the Care Quality Commission (CQC) which helped update their knowledge.Risk assessments and care plans written by the provider lacked detail about how to keep people safe.

People did not always feel they could speak up and that their voice would be heard. The provider did not actively seek feedback from people and staff. The provider had not created opportunities for staff to raise their concerns in line with the providers own policy, for example team meetings and supervisions. Staff told us they did not always feel the provider listened 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 to support a staff member they had made a reasonable adjustment to their work pattern and the staff member confirmed this had taken place. Staff told us they work well as a team, and they do what they can to help each other.

The provider continued not to 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.The provider had failed to make improvements in relation to previous enforcement notices issued to them. The provider continued not to have effective governance systems and processes in place to identify and drive improvements at the service.The governance systems in place had continued to fail in assessing, managing or mitigating risks relating to fire safety, and medicines.

The provider continued to fail to have adequate systems in place to assess, monitor and improve the quality and care provided. For example, care planning documentation did not include all people’s current information. This meant people were at risk of not receiving care that met their needs.The provider continued to fail to have an effective system in place to identify and report safeguarding incidents to the appropriate authorities. Such incidents were still not being appropriately investigated to prevent recurrence nor identify learning.

The provider continued to fail to have systems in place to ensure staff had the skills, supervision and support to develop their roles to provide ongoing safe care or have the confidence to raise concerns to the management.The provider’s own audits continued to not be effective and had not picked up the concerns we identified in this inspection.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not share information and learning with partners or collaborate for improvement.The provider did not demonstrate how they consistently collaborated with others; for example, the provider only sought advice from a relevant professional to mitigate the risks regarding deficient fire doors after prompting from CQC. Furthermore, the provider had not shared potential safeguarding information with the local authority. However, one health partner spoke positively about their experience working with the service and with the staff team. Staff told us how they worked in partnership with health professionals to support people’s health needs.

The provider 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.Team meetings had not been held regularly since July 2024 to share learning and to hear suggestions for improvements. Following our inspection the provider supplied us with evidence of meetings which had been held on August and September 2024, and January and February 2025. Accident and incidents were not thoroughly investigated to ensure learning for the service, or other services where they may have been identified in the incident. Systems were not in place for people, relatives and staff to feedback and contribute to continual improvement.