The Moorings Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this service since registration under the new provider. This key question has been rated inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care.
 

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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs

The provider did not consistently take a person-centred approach to care planning. Care records were often unclear, inconsistent and not kept up to date, which meant staff did not always have reliable guidance to meet people’s individual needs safely.

The provider did not consistently place people at the centre of their care planning or work in partnership with them to respond to changes in their needs. For people living with dementia, care plans did not consistently describe how the condition affected them as individuals. There were no specific, detailed care plans to guide staff on how to provide personalised support to people throughout their dementia journey. This meant staff lacked clear direction on how to meet people’s changing needs.

In addition, some records contained conflicting information. For example, one care plan stated a person “requires two staff and a hoist for all transfers,” whilst other sections suggested they could move independently. This demonstrated a lack of a person-centred approach and increased the risk of inconsistent care.

Relatives told us they were mostly not involved in care planning. Many had not seen care plans or been asked to contribute, with one stating they were “Not involved, no information given, we get informal updates.” Another said “[Persons] care needs have changed significantly” but this was not reflected in records.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

The provider did not ensure that care was consistently joined-up, flexible or responsive to people’s needs. Agency staff were sometimes used and the service failed to provide clear information about people’s needs and preferences to support them in delivering consistent care.

Care records did not always give clear, up-to-date or consistent information about people. This meant staff did not always have the information they needed to understand people’s needs or provide consistent support. Staff told us that handovers, where important information is shared between shifts, had previously been insufficient to keep them informed about changes in people’s health and care needs, although some improvement had started.

The service did not always coordinate care effectively. Work was not always clearly allocated, and staff did not consistently follow up on issues. This reduced the service’s ability to respond promptly and appropriately to people’s needs.

Some professionals told us that the service had started to make improvements in recent weeks following the arrival of a new manager. However, these changes were not yet embedded, and people continued to experience a lack of consistent, well-coordinated care.
 

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs

The provider did not consistently ensure information was shared in a way that met people’s individual needs or supported meaningful involvement from relatives.

Care records identified people’s communication needs and any equipment required, such as hearing aids. However, staff did not always follow this guidance in practice, which meant people did not consistently receive information in a way that met their needs. For example, one care plan stated, “staff are encouraged to use the picture cards when communicating to help [person] express their wishes.” However, during the inspection we did not see staff using or encouraging these tools. This showed a gap between recorded guidance and how care was delivered.

Feedback from relatives about communication was mixed. Some relatives told us communication was clear and that they could ask questions, mostly through verbal updates. However, most relatives reported limited involvement and inconsistent communication. One relative described communication as “Sporadic” and said it “Could be improved,” while another told us, “I would like more information with updates about [person].” One relative stated they had “Never had a sit down with them about [persons] care plan,” and “The poor communication is poor, only the odd email.” They also said, “I don’t get the overwhelming feeling that she is safe, I don’t know if I would recommend it.”

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider did not demonstrate consistent opportunities for people and relatives to formally share feedback or be involved in service improvements. Although the registered manager told us that relatives’ meetings were held, they only provided evidence of one meeting, dated 8 September 2025. Records showed this meeting included discussions about planned improvements, and relatives were given the opportunity to ask questions. However, there was no evidence that further meetings had taken place, despite plans being discussed for early 2026. This meant opportunities for ongoing engagement were limited.

Relatives told us they knew how to raise concerns, and some felt confident to do so. Feedback included, “I know where the manager is”, and “I can talk to them when I go over”.
However, most relatives reported delays in how concerns were addressed. Feedback included, “They aren’t very quick about fixing things,” and “Quite slow to respond to things, they eventually listened to us”.

Some relatives described limited formal communication. While complaint policies and a suggestion box were available, structured feedback processes such as surveys and meetings were not yet well established.
 

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Where people had a disability which impacted their ability to contact health services or access health, care or wellbeing support outside of the home, or into the home if they were unable to leave, people were not consistently supported to have equitable access.

Barriers to accessing health and care services were not considered, and those with higher needs were negatively impacted as a result. For example, we saw some people's care plans lacked information about dentistry services and some stated that their last dental visit was "unknown", when they had lived there for 6 years. One person who had their natural teeth, did not have an oral health assessment in place therefore, dental issues could be missed and not acted upon in a timely way.
 

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider did not fully consider or apply recognised good practice to support people living with dementia. As a result, the environment and available information did not always meet people’s needs or promote independence.

The layout and signage within the service did not support people to move around independently. Corridors were long and lacked clear, easy-to-understand signs to help people find their way. Some communal areas were used for more than one purpose, which created confusion. For example, the dining area was also used as a lounge, but signage still identified it only as a dining room. Similarly, another seating area was used for multiple purposes without clear signage to guide people.

The provider had not introduced tools to help people with dementia make informed choices about food and drink. There were no visual menus or display plates to help people understand what meals were available. This limited people’s ability to make independent choices, particularly where communication needs affected their understanding.

People we spoke with during all three days of the inspection were unable to tell us what they were having for their meals. This showed people were not consistently supported to make informed choices in a way that met their needs.
 

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The provider did not ensure people were supported to plan for future care, including end of life decisions, in a clear, consistent and person-centred way. Care records often lacked detail, were not regularly reviewed and did not reflect people’s current wishes, which placed people at risk of receiving care that did not align with their preferences and could impact their dignity and quality of care they receive.

We found conflicting information about important decisions. For example, a person’s care record showed a DNACPR decision in place, however, their care plan stated, “I do not have a DNACPR and wish to be resuscitated.” Another person’s care plan stated, “I would like my GP to review and discuss with me and my family whether I wish for the further admission to hospital and being resuscitated,” However, this had not been updated despite a DNACPR being introduced and did not reflect the person’s current decision. This created a risk that staff could act on incorrect information at a critical time.

Most relatives told us they had not been involved in planning for future care. This limited opportunities to understand and record what mattered most to people.