Moorfield House

Moorfield House is a residential care home providing personal and nursing care to up to 35 people. The service provides support to people aged 18 and over, some of whom were living with a dementia. At the time of our inspection there were 26 people using the service.

People’s experience of using this service and what we found

Since our last inspection the service had improved in some areas. However, action was still required in relation to care records and the quality assurance system. Care records did not always demonstrate that people were given a safe and suitable diet or fluids which met people’s assessed needs and that steps were in place to safely monitor people with an identified risk of choking.

An effective quality monitoring system was still not fully in place. Improvements had been made to the overall checks and audits, but these were not always completed effectively and did not monitor risks associated with choking.

People’s care and support plans had improved since our last inspection. Care records required a review to ensure all information was accurate and up to date. We have made a recommendation about this.

People were happy with the care provided and enjoyed living at the service. People were complementary about the staff team and the changes that had happened since our last inspection. One person commented, “I think the staff do their very best, they are effective, and improving the service.”

There was improvement with the leadership at the, which had increased staff morale and the culture. Relatives were positive about the improvements that were being made to the service by the management team. A relative said, “The biggest improvement is the stable management regime that [registered manager] has provided. They [the staff] all work together for the benefit of the residents.”

People were safe living at the service and were protected from potential abuse. The home environment had improved and there was a calm, relaxed and pleasant atmosphere.

Medicines were managed safely and there was appropriate clinical oversight in place. Risks which were not related to choking, were well managed and there were detailed assessments for staff to follow to keep people safe.

Staffing levels had been reviewed regularly to make sure people’s needs were met. The management team had reduced the amount of agency staff used and were in the process of recruiting more permanent staff. Agency inductions had improved and the provider’s agency induction processes were being followed. Staff were recruited safely and provided with on-going training and support.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update: The last rating for this service was inadequate (published 12 July 2022) and there were breaches of regulation. We imposed conditions on the provider's registration to ensure that staff were qualified and competent to support people who were at risk of choking, required continence monitoring and oxygen therapy. We requested that people with an identified risk of choking, receiving continence monitoring and oxygen therapy had their care needs assessed and reviewed. We also restricted any new admissions to the home. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made in some areas and we have removed the imposed conditions from the provider’s registration. We have found the provider continued to remain in breach of regulations.

This service has been in Special Measures since 12 July 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to risk management and the quality and assurance systems in place at this inspection.

We have issued the provider with a warning notice because the quality and assurance systems in place did not allow for effective oversight of people at risk of choking.

We have made a recommendation under the effective key question that the provider reviews the care records in place to make sure they reflect the current care and support needs of people.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Moorfield House is a residential care home providing personal and nursing care to up to 35 people. The service provides support to people aged 18 and over, some of whom were living with a dementia. At the time of our inspection there were 31 people using the service.

People’s experience of using this service and what we found

People were not receiving person-centred care that promoted their choice, needs or independence. People were placed at serious risk of harm because care was not delivered safely. Risks people faced were not fully identified, assessed or reviewed. Staff were not always following people’s care plans or risk assessments.

Agency staff did not receive full inductions or have their competencies assessed. There were no records available to demonstrate that the provider was following safe recruitment practices for agency staff. We did not have assurances that staff could safely deliver care to people who had specific dietary needs, required continence monitoring or oxygen therapy.

Staffing levels were not always adequate, and the deployment of staff did not always ensure people were supported safely or had their needs met in a timely way. Staff were observed to be kind and caring with people, but due to staffing levels, they could not fully meet their needs. People did not always receive care from staff who knew them well or were aware of their needs. Staff told us agency staff working with people did not always support them fully.

People were not always treated with dignity and respect or had their independence promoted. During the inspection we observed people having to wait for extended periods of time to receive support.

Medicines were not managed safely. People received their medicines from staff who were not deemed competent in line with the provider’s policy. We could not be fully assured that people who required continence monitoring, were at risk of choking or receiving oxygen therapy where having their needs met and action taken if there was a problem. Medicines were not always given as prescribed and during the inspection we were unable to find assurances that everyone had received their medicines safely.

Care plans were not person-centred and were not always present. Reviews of people’s care needs had been completed but these were sometimes inaccurate and did not reflect on guidance or assessments made by other health care professionals or updates by other staff members. Records relating to the care that people had received were not always present or were incorrect.

People were supported to maintain a balanced diet and were provided with choices for meals. Staff did not always follow each person’s dietary requirement which placed them at serious risk of choking. People had their weights monitored but we found that these were not always regular enough to mitigate the risk of malnutrition.

The quality and assurance systems in place were not effective, audits were not fully detailed, and records were not always present. The provider failed to ensure the quality and safety of the service was monitored effectively. Records at the service, including people's care records, were not always present, accurate or reviewed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Feedback from people and relatives was positive about the staff working at the home. Relatives told us that the staff always tried to do their best but were under a lot of pressure to support everyone. Staff feedback detailed that they did not feel supported, did not have clear leadership nor could they rely on agency staff to support people correctly.

There was an effective infection and prevention policy in place that staff were following. Staff followed government guidance and wore appropriate PPE. Visitors to the home carried out lateral flow tests before visiting and the staff encouraged visits from relatives.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 09 November 2019).

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

The inspection was also prompted in part due to concerns received about medicines management, staffing and person-centred care. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Due to the shortfalls found during the inspection process the provider was requested to produce an action plan detailing what action and by when that they would address the issues identified. We found that not all areas of this action plan which were marked as completed were completed, and people were still at risk of potential harm.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care, person-centred care, medicines management, staffing, competency of staff delivering care, risk monitoring and management, and the governance of the service.

On 13 April 2022, following our first site visit we requested an action plan from the provider to address the shortfalls found during the inspection. We found that not all of the completed actions had been completed when we returned on 27 April 2022 to conclude our inspection. The provider had continued to place people at serious risk of potential harm.

On 28 April 2022, we imposed urgent conditions on the provider's registration to ensure that staff were qualified and competent staff to support people who were at risk of choking, required continence monitoring and oxygen therapy. We also requested that people with an identified risk of choking, receiving continence monitoring and oxygen therapy had their care needs assessed and reviewed. We also restricted any new admissions to the home.

Please see the action we have told the provider to take at the end of this report.

Follow up

We have already requested an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

¿ Systems were in place to help prevent people, staff and visitors from catching or spreading infection. Every staff member and visitor had their temperature taken at the door and were given a mask. Everyone had to wash their hands in the designated handwashing sink upon entering the home.

¿ The environment was very clean. Additional cleaning was taking place, including of frequently touched surfaces.

¿ There was sufficient personal protective equipment (PPE) such as masks, aprons and gloves. Staff were wearing this appropriately when we visited. There was clear signage on the correct use of PPE and handwashing techniques, and staff had received appropriate training in infection prevention and control.

¿ Staff supported people’s social and emotional wellbeing. Local visiting restrictions were in place so people were supported to keep in touch with their family members via video or telephone calls and social media messages.

¿ Infection control audits and checks were carried out. The regional manager spoke positively about the hard work and dedication staff had shown, which had helped to minimise the impact of the pandemic on people's health and wellbeing.

Further information is in the detailed findings below.

Moorfield House is a residential care home providing personal and nursing care to 30 people aged from 18 and over at the time of the inspection, some of whom were living with a dementia. The service can support up to 35 people in one large adapted building.

People’s experience of using this service and what we found

The service excelled at planning and delivering end of life care to people. Staff supported people and their relatives through their final days with complete dignity and offered a high level of personalised support. Relatives were also supported before, during and after people’s deaths and were provided with keepsakes to remember people. The registered manager ensured intensive emotional support was backed up by best practice. This included creating an information booklet to help people and their relatives anticipate and plan.

Staff at all levels respected people’s preferences and individualities. They took proactive steps beyond their job role to learn about people’s cultural and religious backgrounds to better enable them to care for people. This led to exceptional health and wellbeing outcomes for people, particularly reductions in anxiety and the development of new friendships and interests.

All staff ensured people living at the service had extremely engaging sociable lives. The registered manager found creative ways to ensure people were positively engaged; their independence was promoted, and their passions and interests maintained wherever possible. The service was working with people and the local community to reduce the risk of social isolation.

People and relatives were very positive, passionate and complimentary about the service. People received care from kind and caring staff who respected their privacy and dignity. The service worked with people, relatives and other professionals to create personalised care plans which helped to promote people’s independence.

People we spoke to were very positive about the culture of the service and the positive benefits living there had brought to their lives. Feedback provided by people living at the home was actioned immediately by the management team to improve the quality of care provided. The registered manager used this continuous feedback and annual feedback surveys to provide a bespoke service to people.

People and their relatives were very positive and happy with the care provided by staff. Staff knew people very well and were responsive to their changing needs. People and their relatives were involved in all aspects of their care planning, reviews and assessments.

There was a new registered manager in post since our last inspection and staff described her as, “A breath of fresh air.” The registered manager had created a positive and inclusive culture at the service. Staff were empowered to follow their own interests and were provided with additional training to improve the quality of care provided to people. Staff told us about the changes that the registered manager had introduced and said, “I can say I’m proud to work here.”

Staff were supported with regular supervisions, team meetings, learning sessions and appraisals. Staff were safely recruited and received a comprehensive induction from the provider. Training was effectively monitored, and refresher training was provided on a rolling basis.

Staff were encouraged to look at new ways of working to improve the service. The registered manager had worked with people, their relatives and staff to seek feedback and improvement ideas that would improve people’s outcomes and their experience of using the service. Staff told us that they could now provide person-centred care to people, which was individual to their needs, and were no longer task orientated.

The quality and assurance systems in place were used to monitor the safety and care provided to people. The management team used regular auditing to identify further areas and opportunities to continuously improve the service. The management team worked with staff to reflect on best practice guidance, changes to legislation and lessons learned from incidents to improve their overall knowledge and understanding.

Medicines were safely managed and in line with best practice guidance. Risks to people had been fully assessed and mitigated to help keep people safe. People’s care plans were individual and included involvement from other healthcare professionals. The environment was safe and homely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 August 2018) and there were multiple breaches of the regulations. At this inspection, a new registered manager was in place and we found that robust action had been taken to improve. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the service had made sustained improvements and addressed all of the issues identified at the last inspection.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We last inspected the home in January 2017 and rated the home as ‘Requires Improvement’ overall. This was because we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; namely, Regulation 9 (Person centred care), Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). We rated the key questions of safe, effective, responsive and well led as ‘requires Improvement’.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, responsive and well led to at least good. At this inspection we found sufficient improvements had been made to address the key question of safe but the home continued not to meet all the fundamental standards we inspected against for the key questions of responsive, effective and well led. This is the second time the service has been rated requires improvement.

Moorfield House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Moorfield House provides personal and nursing care and support for up to 35 people who require support with personal care, some of whom are living with dementia. At the time of the inspection there were 23 people living there.

The home had a new manager in post who had joined the home in April 2018. The manager had begun the process to become the registered manager. At the time of inspection this registration application had not been received by the CQC. A registered manager is a person who has registered with the Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

At this inspection we found that there were continued breaches of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the governance and quality systems and processes, staff training and staff supervision/appraisal.

You can see what action we told the provider to take at the back of the full version of the report.

People told us that they felt safe living at the home and relatives agreed with these comments. We found there were policies and procedures in place to help keep people safe. Staff had received training around safeguarding vulnerable adults. Staff were safely recruited and they were provided with all the necessary induction training required for their role. The manager monitored when refresher training was required but not all staff had attended refresher courses. Staff had received training in end of life care and there was a staff champion for this.

Accidents and incidents were recorded correctly and if any actions were required, they were acted upon and documented. We observed that there were enough staff on duty to support people appropriately in line with their assessed needs.

During our inspection we found that the premises were safe for people living at the home. Regular checks of the premises, equipment and utilities were carried out but these were not fully documented. Infection control measures were in place and the home was clean. We saw domestic staff cleaning the home regularly during inspection. The premises were not fully ‘dementia friendly’ as the walls, floors and doors were painted in similar colours. There was pictorial signage to help people orientate themselves.

The home provided safe medicines management. Procedures were in place to ensure the safe receipt, storage, administration and disposal of medicines. There were records regarding other professionals involved in people's care. People’s medicine care plans fully documented all of the information needed to fully support people.

People were supported to maintain a balanced diet and we saw people had access to a range of foods and fluids throughout the day. We observed a positive dining experience at the home and relatives also commented to us that they were pleased with the range of food provided.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Staff demonstrated their understanding of the MCA. The manager had notified CQC of these applications.

People had person centred care plans and risk assessments in place to keep them safe. The manager and deputy manager had recently begun to review and re-write people’s care plans to make them person centred. People, relatives and external health professionals were all involved in best interest decisions and mental capacity assessments. People's care records were accurate and up-to-date.

The provider and manager had a clear vision to care for people living at the home. The manager promoted an ‘open door’ policy and staff told us that they felt supported, however they had not received regular supervision or appraisal. The manager was working to implement a new governance framework at the home. At the time of our inspection this was not fully embedded and we found some audits and checks were missing, were not fully recorded or available when we inspected.

People’s privacy and dignity was respected by staff. During the inspection we observed staff asking people discretely if they could carry out personal care and if they required support. The home promoted advocacy and there was accessible information available detailing what support people could access to help make choices about their individual lives. Staff showed kind and caring attitudes and people told us the staff spoke caringly to them. We observed people enjoyed positive relationships with staff. People and relatives knew how to raise a complaint or concern.

There was information on how to make a complaint displayed within the home and this was accessible to everyone. Feedback was sought from people, relatives and visitors to help improve the home.

There was an activities co-ordinator in post but who was absent from the home at the time of our inspection. This meant that people living at the home had not had regular access to organised activities. We have made a recommendation in relation to ensuring that people are afforded opportunities to access stimulating and meaningful activities.

On this inspection we saw progress and plans to address staff training needs. However four further breaches of legal requirements were found.

Moorfield House is a care home which provides nursing and residential care for up to 35 people. Care is primarily provided for older people, including people who live with dementia. There were 23 people living in the home at the time of this inspection. The top floor was currently not being used.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us contradictory things about the service. Everyone we spoke with said that the staff were kind and caring. However, while some people were happy with the care given, others were not. People told us that at times there were not enough staff available to answer their call bell and provide support when they needed it. Care and support was mainly based around completing tasks and did not always take account of people’s differing needs, and there was little time for one to one time with people.

We also received mixed views from relatives about the care. Some said they were satisfied with the care while others said they had concerns about their relatives not getting care in a timely manner.

We recommended that the service undertake a full review of the dependency levels of people to check how many staff are needed to effectively meet people’s needs, and adjust staffing levels accordingly. With consideration given to the roles of staff to determine whether staff were being effectively deployed and managed to best effect.

The training given to staff had improved. The registered manager had reviewed the provision of staff training and begun to address the deficits identified at the previous inspection. We still found a need for this training to be more co-ordinated rather than a blanket provision for the whole staff team.

All staff had been scheduled to receive an annual appraisal during 2017. However we found the frequency and quality of the supervision and appraisals that staff received was poor and did not address practice and staff development issues.

People told us they felt safe. Staff were aware of the different types of abuse people might experience and of their responsibility for recognising and reporting signs of abuse.

We recommended that the provider reassess how staff could access information on safeguarding policies and procedures and how safeguarding could become embedded into the operating systems to have a higher profile in the home.

Possible risks to the health and safety of people using the service were not always assessed and therefore appropriate actions were not always taken to minimise risks. This was in regard to hazards in the home, such as infection control measures, and when managing risks to people falling and behaviours that may challenge the service.

People were supported to meet their health needs and access a range of healthcare services. They were assisted to take their medicines safely by staff who had been appropriately trained. Nutritional needs were monitored and specialist advice was sought when necessary. People were offered a varied diet with choices of meals and, where needed, were assisted with eating and drinking. We received positive feedback about the quality of the meals.

People told us that their family could visit whenever they liked and were made to feel welcome. People spoke highly of the newly appointed activity coordinator and the range of in-house activities that had taken place recently. However people’s ability to go out was limited to staff availability and to having a relative able to take them out.

The majority of care plans were reviewed and updated on a regular basis to reflect changes in people’s needs. We found some were not always updated with the latest advice following a healthcare review.

People told us they were consulted about and involved in their care planning although we found this was not always clearly documented. Many of the care plans lacked detail about people’s personal backgrounds, hobbies and interests.

People’s capacity to make decisions and gaining their consent to care and treatment was not always formally documented.

We recommended that the service looked for good practice methodology in this area so that people’s capacity, ability to give consent and support needs in this area are assessed and recorded more thoroughly.

Some people were not aware of how to make a formal complaint and felt that when they raised issues informally these were not taken up by the management of the home.

We recommended that the service ensured that the complaints procedure is made readily available and is in accessible formats for people to use.

The provider had a range of systems in place for monitoring and reviewing the service, however we found these were not fully effective. Record keeping was not always up to date or accurate around areas such as daily notes, care planning, risk assessments, complaints and on the actions taken to ensure the effective running of the service.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to supporting staff; person centred care; safe care and treatment and governance. You can see what action we told the provider to take at the back of the full version of the report.

We viewed eight private rooms and the communal areas in the home and found a safe and friendly atmosphere throughout. There were two bright and airy communal lounges, a conservatory and a dining room and a garden that was available for people to use for activities but was in need of maintenance and upgrade. We found that the home was safe and fit for purpose and that the registered manager had submitted extensive plans for refurbishment that would make better use of space and provide a more inviting, homely environment for people.

We reviewed the complaints procedure with the registered manager and found that there were no current complaints and that a robust management system was in place to deal with concerns from people who lived there and their family members.

We found extensive evidence of the involvement of people in their own care and comprehensive, readily accessible documentation related to all aspects of safety.