Moorlands Nursing 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 newly registered service. This key question has been rated Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to providing safe care and treatment to people.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The registered manager told us there was a proactive approach to reflecting and learning from incidents within the service. They said, “Myself and [the deputy manager] do the root cause analysis and she does the lessons learnt meeting with staff. Most of it is done with spot checks to check the information has been ingrained.” We observed that falls analysis had been completed for incidents that had occurred in January and February 2026, as well as these being recorded on a tracker so the provider could monitor the number of falls occurring in the service. This could indicate if one person was experiencing a sudden increased number which could indicate a change in need or infection. However, we identified 3 falls that occurred between April and May 2026 that had not been added to the falls tracker. When we asked the registered manager if there was a reason for this, they told us, “I can’t give an answer for that.” Therefore, we could not be assured the provider and management team had full oversight of falls occurring within the service.

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

A recent safeguarding concern raised by healthcare professionals had identified safe systems were not always in place when people required emergency medical input. Despite there being concerns around how the member of staff responded to this and their competence in the role, the same member of staff was asked to work the following day. The deputy manager informed us, “I remained on site until 8pm to meet with [the member of staff] personally, providing guidance and reassurance. I also confirmed that I would be on call and available to offer advice or support at any time should she require it.” However, agency staff were not used to cover the shift, and the staff member was allowed to continue working overnight without supervision from the management team. No action was taken in relation to the other staff member present until 5 days after the incident. This demonstrated there was a potential ongoing risk to people due to safe systems not being in place to prioritise the safety of people.

Another healthcare professional raised a concern that urine and blood samples were only collected and delivered to the GP surgery by staff members at the service once a week. This meant people could potentially go for 6 days without receiving the care they required to diagnose and treat infections. Staff told us this was due to a change in process since the new provider took over the service in December 2025. Previously, the former provider used a taxi service to ensure prompt and regular delivery of samples. However, the current provider relied on staff availability and goodwill, as there was no dedicated transportation. Staff were not always able to take on this additional responsibility, which had resulted in less frequent deliveries to the GP surgery. The operations manager told us, “We can confirm that clinical priority and resident safety always take precedence, and staff are expected to arrange sample collection promptly whenever indicated.” However, the registered manager confirmed there was no formal guidance or process in place on how this would be achieved.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Not all staff understood their responsibility to safeguard people from the risk of abuse and harm. For example, 1 staff member told us, “There was one time when a man said he was frightened of a carer. He had dementia, so I didn’t know if it was true or not. I didn’t want to get in trouble, so I didn’t do anything. I was then on my days off and when I came back the staff member was no longer working here, so it was sorted.” They had not reported this to the management team so that appropriate safeguarding steps could be taken to protect the person. Staff members told us they were scared to raise safeguarding concerns in case they were blamed for them. This had created a culture where a lack of willingness to act on concerns meant people were at potential continued risk of harm and abuse.

However, we observed other safeguarding concerns had appropriately reported to the correct external agencies such as the local authority.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Mental capacity assessments were not always decision specific. For example, 1 person had a singular mental capacity assessment for living at the service, and the ordering, storage and administration of medicines. The Mental Capacity Act 2005 (MCA) states a capacity assessment must be specific to the decision that needs to be made, and the time the decision needs to be made. However, other mental capacity assessments we reviewed were decision specific, such as for the use of bed rails.

Applications were submitted to the local authority, and we saw that applications had considered the least restrictive ways and involved relevant partners in the decision-making process.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans were not always accurate or contained contradicting information about known risks in people’s care needs and health. For example, 1 person’s care plan had contradictory information relating to whether they could use a call bell to alert staff if they needed support. Another person had mental capacity to refuse having fortified meals to improve their weight and nutritional intake. However, there had been no assessment in relation to the risks associated with this. A further person’s care plan stated they were prescribed oxygen for a health condition. However, we found no oxygen was in use at the service and staff confirmed the person no longer used oxygen. Therefore, staff had inconsistent and contradictory information on how they should meet people’s needs and provide their care. We informed the registered manager of this who said they would review all people’s care plans following our assessment to ensure they were up to date and accurate.

Other known risks to people were documented clearly. For example, one person required outpatient treatment at the local hospital twice a week. Their routine around this and the risks involved with their treatment were documented in detail for staff to be aware of. A relative informed us staff managed the risks known around their family member’s mobility safely, saying, “Every time they need to move her, there is always 2 members of staff, they stand her up for transfers and she is really safe, they also check in on her all the time.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider’s business continuity plan was minimal and had only considered action the service should take if there was a shortage of staff. It had not considered other emergency needs of the service such as a loss of utilities, their electronic care system not working, or flooding in the building. This meant plans to ensure people continued to receive safe care during an environmental emergency were not in place.

We observed a cleaning cupboard containing cleaning equipment and fluids had been left unlocked and was accessible to people. Two communal bathrooms were found to be full of wheelchairs and other moving and handling equipment. This meant people could not use the bathroom or toilet in a safe way. Following our inspection, the provider informed us the equipment had been moved out of the bathrooms.

Areas of the home were dated and in need of refurbishment. This included carpets which required replacement and chipped paintwork requiring repair. Works had begun in refurbishing the ground floor flooring at the time of our assessment, although there was no timeline as to when a full refurbishment would be completed.

Other environmental safety checks were in place. This included electrical safety testing, gas safety checks and legionella testing in water outlets.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

People and relatives informed us they felt there was enough staff to meet people’s needs. A relative said, “There are enough staff in my eyes.” Another relative told us, “I’ve got no concerns about the staffing at all.”

Whilst there were enough staff to meet people’s needs, we observed that staff had no additional time to engage with people nor provide a seamless mealtime experience. A staff member told us, “Most of the time there is enough staff, provided we have the activities staff in. The night staff will get people washed and dressed and depending on how many they do, then the morning can be okay.” We informed the registered manager and operations manager of this, who told us they were actively recruiting for another activities coordinator to improve this aspect of the service.

The provider did not have an effective dependency tool in place. A dependency tool is a system that measures the level of support needed by each person living in a service and converts them into care hours. The provider’s dependency tool stated nearly all people living at the service were either medium or high level in their care needs but did not provide confirmation of the care hours needed to provide safe care. The registered manager told us, “They have not given us a dependency tool. When under [the previous provider], we were reviewing the tool all the time.” The local authority was working with the provider to provide templates of more effective dependency tools they could use going forward.

Staff were not up to date with their mandatory training. The provider’s training matrix identified staff were required to complete 24 mandatory training topics. However, one staff member had not completed 11 of these topics, including dementia care, diet and nutrition, falls prevention and duty of care. Two other staff members had not completed 9 and 10 mandatory topics. This meant the provider could not be assured staff had the skills required to provide safe care.

However, staff told us they felt confident in the training available to them. One staff member told us, “I was new to care. I did online training and then shadowing for 2 weeks. I have done my moving and handling training, and all my mandatory training is completed. Since the new company took over, we now have more training to do which I am working through.” However, as previously reported, we identified areas where staff lacked knowledge such as around safeguarding. Therefore, we could not be sure the provider’s training systems were effective.

On the whole, recruitment processes were safe. An issue had occurred where some recruitment files held by the previous provider were no longer accessible, but the administrator had been able to download these and show these when we asked them for additional information to confirm recruitment practices were safe.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed cleaning checklists were in place which were completed in full by housekeeping staff. However, some areas of the service were tired, worn and in need of refurbishment. This meant it would be difficult for staff to effectively clean the environment in a way that could ensure it was free from potential infection. This included a dirty windowsill in 1 bathroom, a door where the paint was chipped, and rusty shower chairs. The registered manager told us, “The carpets are washed every week but sometimes they can’t take it as they’re so old.”

However, relatives told us they felt the cleanliness of the service was high. One relative said, “The place is clean, mum’s room is really clean,” Another relative said, “It’s clean and tidy here, there is always people cleaning.”

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.

We identified some gaps in medicine administration records (MARs) with no reason for the omission recorded. We observed the medicine destruction kit was stored in an open cupboard in which all staff and people had access. National guidance states all medicines and related equipment should be kept in a secure lockable area to prevent unauthorised access.

Whilst room temperature checks were being completed on the whole, the room thermometer was positioned higher than the medicines trolley. National guidance recommends it should be fixed at the same level as where medicines are stored for accurate temperature monitoring. Therefore, the provider could not be sure medicines were being stored in line with manufacturer’s guidance due to inaccurate temperature monitoring systems.

One person told us they were prescribed a medicine which needed to be given at a specific time to manage their symptoms. They told us, “A couple of times last week they were a bit late, and it means my shakes are a lot worse in the afternoon.” We informed the management team of this who said they would look to resolve the issue.

We also identified areas of good practice in medicine management. Medicines were administered by trained staff who had completed up-to-date medication competency assessments and had annual refresher training. Medication rounds were generally unhurried, and staff were observed checking MARs carefully before administering medicines. Protocols and guidance for ‘as and when’ (PRN) medication were in place.