The Moorings 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.

This is the first assessment for this service since registration under the new provider. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safeguarding, premises and equipment, staffing and fit and proper persons employed.

This service scored 31 (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 investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was no clear system in place to investigate and learn from incidents, or to share learning with the staff team. While staff were generally aware of incidents that had occurred, such as a scald from a hot drink or a cut from a wheelchair during transfer, they were not able to share any actions or measures taken to prevent a repeat occurrence.

From review of records, we noted that no incidents or accidents had been recorded for the past 2 months. Management agreed this was unlikely and told us that staff lacked knowledge to flag events as incidents. For example, leaders told us a person was found on the crash mat nearly every other day, however, this was not being recorded as an incident.

There was not yet a system in place to review accidents and incidents or complaints. Management confirmed at the time of inspection that there had not been any learning from incidents yet or communications to staff. This could mean patterns or trends were not identified, and opportunities to improve safety for people may be missed.
 

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

There were no clear systems in place for people transitioning between services. People did not receive continuity of care in a person-centred way as care records contained inconsistencies and did not accurately reflect the person’s current level of needs. This meant information could not be easily provided to other professionals or hospital should the person be admitted.

The provider did not have a robust and safe system in place to ensure that people’s care records contained sufficient guidance for staff to follow. We found there was a lack of clear, timely and consistent information about people’s health needs where they may be receiving care from different services.

The provider was unable to demonstrate that people were provided with an up to date service user guide on admission containing relevant information for them about the service and their transition into residential care.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider failed to ensure people were protected from abuse and improper treatment. Safeguarding events were not consistently recognised so that action was taken to protect people from harm. The provider failed to identify and notify the relevant agents about potential safeguarding incidents. We identified several incidents that met the threshold for a safeguarding referral and were notifiable to CQC, however, these referrals had not been completed.

Systems to ensure service users received food modified to the texture required was inadequate, which led to repeated incidents over the 3 days of our inspection. We observed 9 people being provided with food items not in-line with their prescribed modified diet. IDDSI (International Dysphagia Diet Standardisation Initiative) is a globally standardized framework used to describe texture-modified foods and thickened liquids for individuals with swallowing difficulties (dysphagia). Staff lacked the sufficient understanding of how each person required their meals prepared to manage the risk of choking and dysphagia. The management of IDDSI and the lack of staff understanding and knowledge placed people at significant risk of harm. We raised a safeguarding referral to the local authority.

Risks of injury, including entrapment which can result in suffocation or injury, from use of bed rails were not assessed and managed appropriately. The provider had not always sought people’s consent or assessed their capacity to agree to this restriction. Therefore, some people were unlawfully restricted. This included a person whose risk assessment for bedrails clearly identified they were at high risk of entrapment. However, at the time of our inspection, bedrails were still in place.

Where people had an authorised Deprivation of Liberty Safeguards (DoLS) in place, conditions had not been met. For example, a condition was to facilitate a bedroom move for a person as soon as possible to enable them to continue to mix with other people in the event that the lift breaks down, however this had not taken place even though there was a vacant bedroom. This condition had been valid for 3 months and during this period the lift had failed.

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.

Individual safety risks were not comprehensively assessed, understood or monitored. Care records for people who had health conditions such as Epilepsy, diabetes and heart conditions were not sufficiently detailed to ensure staff had the information required to care for people safely and effectively. For example, where people had a diagnosis of epilepsy / seizures and were prescribed medicines, there were no risk assessments or care plans in place to support and guide staff. When speaking with staff they told us 2 people had epilepsy, however we identified 4 people had seizures. The provider failed to ensure that all staff had the required training for this condition, we noted only one member of staff had received training in epilepsy.
Safety risks in relation to diabetes and heart conditions were not comprehensively assessed, understood or monitored and care plans lacked important information about the condition. We reviewed records for 3 people who had a diagnosis of diabetes and found no guidance that enabled staff to effectively monitor their health. For example, there were no care plans or risk assessments in place, there was no information in relation to monitoring of blood sugar levels, frequency and people’s individual target ranges. This information is vital to ensure the safe management of diabetes and in the event of a diabetic emergency, or to ensure people receive timely medical intervention.

A person who was prescribed medicine for a heart related condition did not have a care plan or risk assessment in place. This meant staff did not have vital information they needed to be aware of, such as signs and symptoms of the person becoming unwell and when to seek urgent medical help in the event of deterioration.

Some bedrails did not have covers, and others had bumpers that did not fully fit, which created a risk of entrapment. We also found bedrail equipment stored on top of people’s wardrobes, with no clear system to confirm it was used when required.
 

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 did not ensure the environment and equipment supported safe, effective care or people’s independence.

Bathing facilities were not maintained. There was only 1 bath, which had been out of use for several months. Although management stated it was ready for use, we found it had not been installed or connected. This limited people’s access to appropriate bathing facilities.

Equipment to support people’s care was not always reliable. Staff reported that only one hoist was working consistently and that equipment was difficult to move between floors. This could impact the safe delivery of care and people’s comfort.

Bedrail safety was not consistently managed. The provider could not demonstrate that regular safety checks had been completed.

Fire safety arrangements were not fully effective. The provider could not demonstrate that simulated fire drills had been carried out or that training in the use evacuation equipment had been provided to prepare staff in the event of a fire emergency. Important emergency information, such as personal evacuation plans, was not available in the emergency bag. The fire risk assessment completed 20 November 2025 had 22 actions that all required rectifying within one month, however, there was no evidence to demonstrate that these concerns had been addressed.

Systems to monitor the safety of the premises were not robust. Records relating to water safety checks were incomplete, and the provider could not demonstrate an up-to-date Legionella risk assessment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always 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.

The provider could not always be sure staffing levels were sufficient to meet people’s needs as they were not using a systematic approach to determine staffing levels. We reviewed the staffing rotas which did not clearly identify management or deputy cover, and whilst additional staffing had been agreed, there were inconsistencies between the stated numbers and the recorded numbers. During our inspection we observed periods of limited staff interaction and delays in supporting people, including individuals remaining seated for prolonged periods after meals, indicating staffing deployment did not always ensure timely, person centred care.

The provider could not be assured all staff had the essential skills and knowledge required to deliver care safely and effectively. There had been very little training completed since the transfer of ownership in September 2025 and staff themselves were unsure of their training histories. The provider had recently introduced a new online training system, and staff told us that new eLearning had been allocated and they each had about 30 courses to complete in their own time.

The provider failed to undertake recruitment checks in line with regulatory requirements. Recruitment and staff file checks identified significant gaps and inconsistencies across several staff records. The providers systems did not consistently ensure robust pre employment checks, accurate employment histories, or appropriate risk management. This included the requirement to obtain satisfactory evidence of conduct and satisfactory verification of why employment ended in all employment concerned with the provision of services relating to health or social care, or children or vulnerable adults.

The provider did not always assess or manage the risk of infection. Whilst there were some systems in place to support infection prevention and control, including cleaning routines, access to personal protective equipment (PPE), and safe storage of cleaning chemicals, these systems were not always applied consistently in practice.

We identified concerns relating to cleanliness, equipment hygiene, food safety, and staff infection control practices.

We observed unclean equipment, including wheelchairs. A Sara Steady was used to support two people but was not cleaned between use, increasing the risk of cross-infection. In addition, one person’s bedroom had a strong odour of urine. We requested that the person be moved to an unoccupied room. The registered manager told us this was a “historic issue.” However, although this concern had been raised at the previous inspection under the former provider, the service had been under new ownership for eight months at the time of our inspection. We also observed another person’s carpet was heavily stained.

We found further concerns with hygiene and infection control practices. These included unclean bedding that was not addressed in a timely way, inappropriate storage of out-of-date food, and staff not always following good hand hygiene standards.

While many areas appeared clean and tidy on the surface and cleaners were observed carrying out their duties during the inspection, these issues demonstrated that infection prevention and control processes were not consistently followed or effectively monitored.

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

Staff stored medicines securely and maintained appropriate records for medicines requiring additional checks. They recorded fridge and room temperatures, which assured that medicines remained within manufacturers’ recommended ranges. However, the provider did not demonstrate that they had obtained and implemented expert advice regarding the storage, signage, and use of medical oxygen, including the planned preventative maintenance of oxygen concentrators required for safe use.

We identified variation in the quality and location of medicines-related records. These variations included inconsistencies in recorded allergies across different documents, discrepancies between care plans and "when required" (PRN) medicine protocols, and differences in records relating to medicines authorised for covert administration under DoLS. Staff did not always record monitoring results consistently, and they used different locations to record the application of creams. We found that staff had reviewed some PRN protocols and improved them with more personalised information; however, they needed to develop most of these documents further, particularly where multiple medicines were prescribed for a single condition (for example, constipation). Staff did not have variable dose protocols to guide them when administering medicines with flexible dosing. In addition, escalation guidance did not clearly distinguish between contacting NHS 111 and emergency services, which created a risk that staff might make inconsistent decisions about residents’ care depending on which records they consulted.

Emergency preparedness was also affected because staff did not include Personal Emergency Evacuation Plans (PEEPs) in emergency grab bags. This omission increased the risk that staff would not have access to essential information needed to provide safe and appropriate care in urgent situations.

Staff recorded the application of creams used during personal care in the e-care records system. A member of care staff showed us where they stored these creams. The creams we inspected were labelled with opening dates and revised in-use expiry dates. The staff member explained how and where they recorded cream applications and where they could find additional information about them.