Moorland Gardens 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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance. The provider had not always ensured their systems were effective or ensured oversight of quality, safety and management of risks.
 

This service scored 57 (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 clear shared vision, strategy and culture and demonstrate they always understood the challenges and the needs of people and their communities. We found inconsistencies in day to day‑ practice the leadership team had not identified, including gaps in missed incidents, people experiencing restrictive practice that had not been planned for and inconsistent responses to people at times of distress. This meant there was an increased risk person centred‑ practice and culture were not yet fully embedded across the team.

However, relatives told us the atmosphere in the home was friendly and welcoming. Staff delivered routine care reliably, and engagement efforts improved over the course of our visits. Staff said, “Some team spirit is good… new staff can be nervous, but we support them.” Another told us, “We have a lot of staff that have stayed a long time.”

During this inspection we identified 4 breaches of the legal regulations. This meant leaders did not demonstrate they had the skills, and oversight to lead effectively. However, relatives described leaders as responsive when concerns were raised. A relative told us, “The manager is polite, accessible and easy to talk to.” A staff member told us, “The manager’s door is always open, we can just knock and go in.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. All staff we spoke with confirmed they felt able to raise concerns to the provider if they needed to.
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff did not raise concerns in relation to workforce equality, diversity and inclusion.

Governance systems were not sufficiently robust. Oversight processes had not identified concerns we found around incident reporting, safeguarding, care planning, and unsafe moving and positioning practice and environmental safety.

However, improvements were made or planned after we identified these concerns. The provider told us they had increased the frequency and structure of governance arrangements. We will check for sustained improvement at our next inspection.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. People and their families felt able to contribute their views, and the service-maintained links with external health professionals to support people’s needs.

We found that learning and improvement were not consistently embedded across the service. Several concerns we identified during the inspection, such as inconsistencies in documentation, gaps in recognising or responding to distress, and variations in daily practice, had not been picked up through the provider’s own governance processes. This indicated that systems for identifying themes, analysing risks and driving continuous improvement were not always well established or operated effectively.