The Moorings 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance at the service and failure to notify.

This service scored 36 (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 did not have a clear, shared vision or strategy in place at the time of the inspection. A new manager had been in post for five weeks, alongside a registered manager who had been in post since September 2025. Systems to embed a clear direction for the service had not yet established.

The provider’s statement of purpose did not contain accurate and up-to-date information. Although it included details about the provider and the new manager, it did not include information about the registered manager who remained in post. This meant people and their relatives were not given fully accurate information about the leadership of the service.

Leaders had not yet developed consistent approaches to support staff engagement or morale. There were no formal staff incentive schemes in place. The new manager told us they had introduced a group communication channel and an open-door approach to improve accessibility and support. While these actions showed early progress, they were not yet embedded or supported by clear evidence of sustained improvement.
 

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. Leaders 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 a registered manager who had been in post since September 2025 and along with the provider, they are responsible and accountable for the running of the service and the oversight of quality and safety.

The registered manager and provider failed to demonstrate their capability to identify and address risks without delay. The concerns identified at this assessment as detailed throughout this report had not been identified or effectively managed until highlighted by inspectors. The registered manager and provider did not demonstrate they had the knowledge and experience to ensure regulatory requirements were met due to the significant shortfalls identified during this assessment.

The concerns identified at this assessment mirrored the historic failings previously identified by CQC for which the provider and registered manager were aware of.
 

People did not always feel they could speak up and that their voice would be heard.

The service did not consistently foster a positive culture where staff felt able to speak up. A significant minority of staff fed back in staff surveys that did not feel comfortable raising concerns, which suggests that people did not always feel confident their voice would be heard.

Leaders had not fully established clear or accessible processes to support speaking up. The manager told us they were using a standard policy template that had not yet been adapted to the service. Staff were also not aware of complaints that had been raised, which limited opportunities for shared learning and improvement.

Though we saw some supportive messages from leaders towards staff. We found some indication of a blame culture from the provider and registered manager. This may discourage staff from raising concerns openly and reduces the likelihood that issues will be identified and addressed promptly. Overall, this limited the service’s ability to promote openness, learning and continuous improvement.
 

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider demonstrated a commitment to diversity and had a varied and inclusive staff team. Leaders told us they would support and respect staff members’ individual needs. We saw examples where managers provided emotional support and showed awareness of staff wellbeing. This indicated a supportive approach and an understanding of the importance of treating staff fairly.

However, while leaders described a positive approach, systems to formally monitor and evidence how equality, diversity and inclusion were promoted across the workforce were limited.
Overall, the provider showed a willingness to support an inclusive culture, but further development was needed to ensure this approach was consistent, measurable and fully embedded across the service.

The provider did not 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.

Governance systems were not effective and did not ensure the service was safe or consistently delivering good quality, person-centred care. The provider and registered manager failed to identify or address a number of significant concerns found during the inspection.

Audit systems for identifying, capturing and managing organisational risks and issues were ineffective. They were not robust and did not provide an effective system to systematically identify the concerns found during this inspection. This included a lack of monitoring of environmental risks such as fire safety, water safety and the safe use of equipment. There was limited evidence of provider or registered manager oversight in these areas.

Care records were not always complete, accurate or up to date. Some records lacked sufficient detail to guide staff in meeting people’s needs safely. In addition, risk assessments were not always completed for known risks, which increased the likelihood of harm.

The provider did not meet their legal responsibility to notify the Care Quality Commission (CQC) of significant incidents. For example, records showed multiple occasions where incidents had been reported to the local authority safeguarding team but not to CQC. A review of records identified at least 19 safeguarding incidents in a 3 month period that had not been notified.

The registered manager acknowledged gaps in reporting, stating, “You’ve got some but not all.” Records also showed that some incidents, such as a person being scalded by a hot drink or one person kicking another, had not been referred to safeguarding or reported to CQC.

Although the new manager understood when notifications should be made, they confirmed they had not submitted any since starting in post. There was no clear system in place to ensure all reportable incidents were identified and submitted as required.

The provider did not have effective systems to monitor safety, manage risk or ensure compliance with reporting requirements. This meant risks were not always identified or addressed, placing people at increased risk of harm and reducing opportunities to improve the quality of care.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not consistently work in partnership with others to provide joined-up care or improve outcomes for people. Although 1 healthcare professional reported recent improvements in partnership working, this was not yet consistent or fully established.

Leaders had identified the need to strengthen links with local organisations and community groups to support people’s interests and wellbeing. However, these plans had been in place for some time without clear progress. This limited opportunities for people to benefit from meaningful activities and community involvement.

Staff told us that people were not regularly accessing the community, and people were not supported to leave the home or access the garden, except when supported by family members, which reduced their connection with local services, groups and opportunities. Overall, the service did not yet demonstrate effective collaboration or engagement with partners to support people’s wellbeing or drive improvement.
 

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.

The provider did not consistently promote a culture of learning, improvement and innovation.

We found multiple concerns during the inspection that the provider and registered manager had not identified. This included 11 breaches of legal regulations, which showed systems to monitor quality and safety were not fully effective.

The provider had not ensured lessons had been learnt from known historic concerns. This meant there were continued shortfalls in the quality and safety of the service and care provided to people which placed them at continued significant risk of harm.

The provider did not have clear systems in place to review incidents, identify lessons learned, and drive improvement. This meant their ability to respond proactively and prevent issues from recurring was limited.

We acknowledge that a new manager had been in post for five weeks at the time of our inspection and had plans to introduce systems to support learning and improvement. However, these were not yet in place, and we did not see evidence of a structured approach to learning or continuous improvement at the time of our visit.