Moorleigh 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.

At our last assessment we rated this key question good. At this assessment, the rating as 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 regulation in relation to good governance

This service scored 62 (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 had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding of the challenges and the needs of people and their communities.

This was evident in the way staff consistently worked in line with the provider’s values of transparency, equity, and inclusion. Staff consistently described strong teamwork, a sense of belonging and a culture where colleagues supported one another, including during periods of personal difficulty. Most staff felt the provider’s values were evident in day-to-day practice. Interactions observed between staff and people were compassionate and respectful, and relatives reported many positive examples of kind and attentive care.

Leaders were approachable and staff told us they felt supported in their roles. The registered manager was visible in the service and staff said they checked in with them and encouraged their development. Staff described leaders as compassionate and said they promoted a positive team culture where concerns could be raised openly.

Staff were described as reliable and willing to offer guidance and support to each other. Staff told us communication across the service was good. These approaches helped create an inclusive and supportive environment where staff focused on delivering good care. One staff member told us, “We have a daily hand over where we get told any updates and changes and the nurses are also always on hand for us to ask.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The management team operated a positive culture where people felt they could speak up and their voices will be heard. People were provided with opportunities to share their views and experiences regarding the care they received. For example, resident meetings were heldfrequently, creating a forum where people could voice their concerns, offer suggestions, and participate actively in discussions about the quality and delivery of care.

Staff members participated in handovers designed to facilitate the ongoing review of care practices. These meetings, provided staff with an opportunity to discuss recent developments, address any pressing concerns, and collaboratively review procedures. The purpose of these meetings was to ensure that care remained responsive, effective, and aligned with peoples’ needs.

Staff demonstrated a clear understanding of the organisation’s whistleblowing policy. They communicated the purpose of whistleblowing as reporting unsafe or harmful practices when routine reporting channels have not resolved concerns. Comments included, “Whistleblowing iswhen someone reports wrongdoing they’ve seen in a workplace or in an organisation.

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 reported that they could request reasonable changes to their work schedules to accommodate requirements, such as family responsibilities.

We saw that the provider had an up-to-date equal opportunity policy. This policy was designed to ensure that hiring, promotion, training, and other employment decisions were based solely on merit, without discrimination based on factors such as gender, race, age, disability, or socio-economic background.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance audits were regularly completed; however, they had not always identified where improvements were required. There were gaps in recognising a lack of recording in daily monitoring forms, no audits of daily notes or the dining experience. There was no evidence of call bell audits being undertaken when asked about this the registered manager confirmed that this was not available on the system that was installed.

There were also failures to identify risks in medicines management, which exposed people to the possibility of receiving their medicines unsafely for example, topical creams not evidencing an open date and not being stored safely, patch and injection site rotation not being undertaken as required. These issues highlighted weaknesses in governance systems, where audits did not always provide effective oversight or assurance of safety and quality.

The registered manager had identified that refurbishment work to the building was required and confirmed that this had been escalated to the provider, however a significant amount of this work remained outstanding.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly wherever possible for people. Commissioners told us the staff and management team had worked to improve in some areas of care identified. External health professionals spoke positively about the care team and praised their effective communication. We saw evidence of the staff team working in partnership with a wide range of health professionals. These included the tissue viability nursing team (TVN), occupational health, social workers, the speech and language therapy team (SALT), the local GP and the pharmacy. Care staff also accompanied people if needed to attend appointments in the community.

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. Although some learning practices had been introduced such as systems to capture lessons from incident audits these were not applied consistently across the service. The provider’s quality assurance processes were not implemented effectively and failed to identify several shortfalls highlighted during this assessment, including issues in medicines management. We also found that certain areas, such as the mealtime experience and call bell response times, had not been monitored effectively. As a result, the provider was unable to reliably analyse or share learning as required to support staff development and drive improvement.