Moorlands Nursing 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 newly registered service. 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 governance and oversight of the service and not fulfilling their regulatory responsibility of informing CQC of notifiable incidents.

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.

There was a poor culture in the service, in which staff were scared for their jobs. One staff member told us, “I don’t know what is going on, but there was a lovely carer and now she’s just gone. Two others have gone too. No one knows what happened. Everyone is on edge and worried about their jobs. There is not a good atmosphere.” Documents we viewed also demonstrated a culture of fear. A governance report from April 2026 stated, “Unless staff complete training including outstanding Safeguarding within 5 days, staff will be suspended.” However, the provider had not provided additional time or staff cover to allow staff to complete this without fear of repercussions.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

People and relatives had varied experiences since the new provider took over in December 2025. One person explained to us, “There is new management and it’s still early days. They did a meeting when they took over.” A relative told us, “I understand things have changed since the new management, they have gone down a little.” Another relative said, “Take overs of management are never easy, I know that. Sometimes things are not pretty but that happens all the time with this sort of thing.” A further relative said, “The new management is shocking. The place is not being managed properly. [The registered manager] is fine but she is going.” A further relative added, “[A senior leader] sits on [their] laptop in the dining room taking a table of 4 up, doesn’t interact with anyone at all.” We fed this back to the senior leader so they could reflect on their presentation and communication when in the service.

The registered manager also voiced she felt there was a lack of support from the management above her. Records evidenced that the registered manager had told the operations manager they did not feel supported and felt their communication was ignored or disregarded. However, there was no actions to demonstrate what the operations manager had taken to provide the registered manager with support to resolve the issues.

Feedback on the registered manager was positive. A relative said, “[The registered manager] is fantastic.” Another relative added, “[The registered manager] is really nice.” A visiting professional told us, “She has provided much needed continuity, and I very much believe she had the best interest of the home and the residents at heart.”

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

We received mixed feedback from staff on their confidence to raise concerns if they needed to. One staff member told us, “It is my right to speak up.” The registered manager stated, “I think staff are afraid to speak up now though as they are scared to lose their job.” Other staff members told us this was correct and they feared repercussions such as losing their job if they did speak up about concerns. This was evidenced when a staff member told us they had not reported a safeguarding concern due to this reason.

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

Staff members informed us they felt a senior leader was discriminating against staff members from a specific ethnic background. Staff believed certain staff members received preferential treatment from management and expressed that they did not feel listened to when raising issues. Staff indicated that they were reluctant to formally report these concerns due to fear of repercussions, as the discrimination was believed to originate from the provider. They expressed anxiety about potential impacts on their employment if they spoke up.

The provider’s disciplinary policy stated, ‘SES Care Homes Ltd adheres fully to the Advisory, Conciliation and Arbitration Service (ACAS) Code of Practice Disciplinary and Grievance Procedures.’ However, a visiting professional stated they believed this was not the case, stating “We would expect the employer to follow ACAS guidance, however there has been many clear breaches throughout. The [senior leader] has acted so widely out of process on every occasion and has not followed a particular policy. I have found the [senior leader] to be dismissive, hostile, and show a distinct lack of regard for fair procedure. At no point have workers been informed of their rights. Throughout all of the meetings [the senior leader’s] presentation, tone and refusal to accept, nor present evidence has been suggestive of a predetermined decision to dismiss.” We raised this with the senior leader who informed us they were aware there had been internal complaints made about them in regard to discrimination. They told us, “All I can say is that within all our homes we have, and that is from the owner downwards, we have a very diverse, multicultural staff team. And so, I don't think anybody could accuse us or accuse me of discriminating.”

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.

The management team recorded instances of safeguarding concerns they were aware of in a central folder. From this, we identified since January 2026 there had been 14 occasions unexplained bruising had been identified on people and 7 unwitnessed falls. Registered person’s have a legal responsibility to inform the Care Quality Commission (CQC) of incidents of this kind. However, we had received 10 notifications only in regard to these incidents since January 2026, meaning we had not been informed of all instances of alleged safeguarding issues including unexplained bruising and unwitnessed falls. This demonstrated the provider was not informing us of notifiable information in line with their legal responsibility.

Governance audits were being completed but were not effective in their use. For example, a catering, food safety and kitchen hygiene audits dated April 2026 stated all staff were trained in dysphagia. However, the provider’s training matrix identified that 9 staff had not completed training in this area. In a care planning and personalisation audit dated February 2026, the provider had marked themselves as being 97% compliant. We identified that this was not the case. Where any shortfalls had been identified by the management team, no follow up actions with dates of completion or person responsible for resolving the issue were documented. Therefore, the provider could not be assured that shortfalls identified in the service were being appropriately resolved.

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

Feedback from external stakeholders highlighted a strained working relationship with the service. One professional told us, “Staff aren’t always the easiest to communicate with, they’re not particularly welcoming.” Another visiting professional told us, “My concerns with Moorlands mainly started when the new owners have taken over. I believe I have only met [the provider] in passing once or twice. I introduced myself but neither were keen to engage in any discussion or communication. Last week when I needed to discuss [an illness] outbreak with the management team and could not find [the registered manager or deputy manager. I asked to speak to [the owner] but he declined this and asked me to wait for [the deputy manager].

The local authority had been chairing support meetings with the provider in the lead up and following our assessment. Throughout these meetings, issues such as a dependency tool not being used were discussed, and the local authority have offered assistance with creating a tool for the service. However, the provider to date had not utilised the support offered.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There were missed opportunities to reflect and make improvements on care. Despite various stakeholders and relatives providing feedback to the provider, little action had been taken to address and resolve any issues raised. For example, during our inspection we identified the sluice room door were left open. Sluice rooms should always be locked as the area is used for disposing of human waste and disinfecting medical items. We informed the registered manager of this who informed us they would remind staff to keep this room locked. However, the local authority quality assurance team had identified it was left open on visits prior to our assessment, and again during a visit to the service 5 days later.

Staff did feel some improvements had been made at the service. One staff member told us, “One positive I’ve heard the care staff say is that there is a now a fully stocked kitchen and there are plenty of pads too.”