The Moorings Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service since registration under the new provider. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulations in relation to need for consent and meeting nutritional and hydration needs.

This service scored 33 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People did not consistently receive care that reflected their individual needs. Staff did not always involve people in assessing their needs or in developing their care plans.

Assessments were not always completed or updated in a timely way. Where assessments were in place, some contained inaccurate or inconsistent information and did not reflect the complexity of people’s needs, including risks, physical health and required levels of support. For example, a person’s care plan consistently detailed they were independently mobile, however, this was incorrect as they required 2 staff and the use of a hoist to transfer.

As a result, records did not always provide staff with clear guidance to deliver safe, effective and person-centred care.

The provider did not always plan and deliver people’s care and treatment with them. They did not always follow legislation and current evidence-based good practice and standards.

People were placed at risk of malnutrition and dehydration because staff did not use recognised assessment tools effectively. For example, staff identified that some people required weekly weight monitoring but only carried this out monthly. This meant staff may not identify unexplained weight loss promptly, leading to delays in taking action or making referrals.

Staff used a recognised tool to assess risks to people’s skin; however, they did not consistently follow the actions needed to reduce these risks. This included failing to reposition people as frequently as required and not using specialist equipment correctly. For example, staff set one person’s pressure mattress incorrectly for their weight. Although managers addressed this at the time, it showed that existing systems were not effective.

We also found significant gaps in repositioning records. The provider could not demonstrate that staff supported people to change position as often as required to maintain their skin integrity. This placed people at increased risk of harm.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We identified concerns in how staff monitored and responded to people’s routine health needs. For example, we found two people had very long toenails. Records for one person showed staff had only checked their nails twice over a 42-day period. Although the care plan stated the person received visits from a chiropodist every 6 to 8 weeks, a lack of regular checks meant staff did not identify the need for earlier intervention.

We raised this with the registered manager, who confirmed a chiropodist visit was planned shortly after our inspection. However, the lack of ongoing monitoring showed that staff did not act promptly to meet the person’s needs.

We also received feedback from a relative who said they had to raise concerns with the manager about their loved one’s toenails. This issue was resolved following their complaint.

We saw some evidence that people could access other healthcare professionals, such as GPs and district nurses. However, the concerns identified showed that coordination and oversight of care were not always effective.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Staff did not always provide consistent support to meet people’s nutritional needs. Staff did not offer snacks regularly throughout the day, including for people who required additional nutrition outside of main meals.

Staff knowledge of available food options was limited. During the inspection, staff told us the only snacks routinely offered were biscuits. There were limited suitable options for people who required soft or moist foods. Although alternatives such as yoghurt were available, staff did not routinely offer these. We raised this with the management team, who were not aware of the lack of choice. In at least one care plan, staff had identified that the person required regular snacks, but staff did not consistently follow this.

Records did not show staff offered snacks consistently. Where people had been prescribed nutritional supplement drinks, records showed these were not given daily as required. For example, records for one person showed that staff had not recorded giving the prescribed daily supplement on most days.

We also observed limited encouragement from staff to support people to remain active. Staff did not consistently promote activities that support strength, balance and mobility.

These concerns showed that staff did not always support people to manage their health and wellbeing effectively or reduce the risk of deterioration.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Staff did not consistently monitor people’s weight as required. We reviewed records for four people who had experienced weight loss. One person had lost over 10% of their weight within six months. In March 2026, staff had been instructed to record their weight weekly, however, records showed this had not completed since 25 March 2026. A second person had also been assessed as requiring weekly weight monitoring; however, staff had not recorded their weight for several weeks.

Staff did not effectively monitor people’s fluid intake. Records over a six-week period showed that staff did not always offer or provide people with the amount of fluid they required. For example, 1 person did not receive their assessed daily amount of fluid on 41 out of 42 days. Another person did not receive their required fluid intake on any of the days reviewed. There was no evidence that staff or leaders identified these concerns or took action to reduce risks. Staff had not completed risk assessments for people at risk of dehydration.

Care planning did not always provide staff with enough information to support people’s health conditions. For example, one person with a bowel condition did not have a detailed care plan to guide staff on how to manage the condition. The plan did not include advice on how to reduce the risk of complications or when staff should seek medical help if the person’s condition worsened.

We observed staff supporting several people to transfer using hoists. However, records did not always accurately reflect the equipment staff used. Staff also gave inconsistent accounts of people’s mobility needs. This meant records did not provide a clear or reliable picture of how staff supported people, including whether people could safely use less restrictive equipment.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider failed to ensure the correct procedure was followed in relation to the Mental Capacity Act 2005 (MCA). The MCA 2005 provides a legal framework for supporting people who may lack the ability to make certain decisions for themselves.

The provider did not always assess people’s mental capacity to make specific decisions in line with the MCA. This included decisions such as, modified diets, receiving regular welfare checks, use of mobility equipment such as hoists and having photographs taken. It also included the use of restrictive measures, such as, bedrails and sensor mats. Some mental capacity assessments identified several specific decisions on 1 assessment which was not in line with the code of practice.

Decisions were often reflective of the outcome and were not reflective of making decisions about people’s safety and support required to manage a risk. For example, mental capacity assessments in place started with a restriction. This practice in relation to best interest decisions did not meet MCA requirements. The provider failed to show they had considered less restrictive practices when they were making best interest decisions in relation to restrictions on people. Therefore, the decisions made may not have been proportionate and the least restrictive option.