Moorland House

Moorland House is a residential care home providing personal care to up to a maximum of 23 people. The home does not provide nursing care. At the time of our inspection there were 15 people using the service, some of whom were living with dementia. The accommodation at Moorland House is arranged over 2 floors accessed by a passenger lift and by stairs. There is a communal lounge 2 dining areas and a secure garden area.

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

Risk to people had not always been assessed and risk management plans were not always in place to guide staff. Improvements were needed to ensure the safe and proper use of medicines, and infection control risks were not consistently being managed safely. Staff recruitment processes did not promote safety. Observations indicated that were sufficient numbers of staff deployed, but we were not assured that staff were always suitably knowledgeable and skilled. Improvements were needed to ensure that robust investigations consistently took place to establish the reason for incidents and accidents so that learning might be shared.

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. However, improvements were needed to ensure that the Mental Capacity Act 2005 was fully understood and implemented in line with legal frameworks. Care plans lacked completeness or contained conflicting information.

Improvements were needed to ensure that each person was provided with the support they needed with their dietary needs. Completion rates for developmental or specialist training which was designed around the needs of people using the service was poor and we were concerned about the competence of some staff, their ability to apply their training in practice or to effectively communicate with people. The provider, who had taken on ownership of the service in July 2022, had an extensive plan in place to undertake improvements to the environment. People felt that staff supported them to stay as well as possible and there was evidence that staff worked with a range of community healthcare professionals.

Governance arrangements were not effective at identifying all of the areas where the safety and quality of the service was compromised. Feedback described cultural issues amongst some of the staff team which had detracted from the ability of the new leadership team to manage the service effectively and drive improvements as quickly as they would have liked. The provider is taking action to put in place additional support, a new manager has been appointed and an external consultant hired. People spoke positively about the new provider and of their commitment to listen to their feedback and use this to improve the service.

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 20 November 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from good to requires improvement with breaches based on the findings of this inspection.

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

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Moorland House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment, governance, recruitment, safeguarding people from abuse and the need for consent.

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.

Moorland House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality 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.

Fire and legionella risks assessments needed to be more robust. Infection prevention and control procedures continue to require some improvement.

Improvements had been made to ensure staff received training, supervision and appraisal to provide them with the required skills, knowledge and competencies for their roles.

There was a positive, supportive and open culture within the home. Staff felt supported and listened to by the registered manager and providers who were visible and approachable.

People were protected from abuse. Staff had received training in how to keep people safe from abuse and understood how to identify and report abuse if they suspected abuse was taking place.

Safe recruitment procedures ensured only suitable staff were employed. There were sufficient staff deployed on all shifts to meet people’s needs and keep them safe.

The management of people’s medicines was robust. Staff received training in administering medicines and people received their medicines as prescribed.

Risks associated with people’s health, safety and welfare had been identified and assessed. Emergency evacuation procedures were in place and known to staff.

People’s rights were protected because staff understood the principles of the Mental Capacity Act (MCA) 2005). Deprivation of liberty safeguards had been submitted to the local authority for authorisation when required.

People were supported by staff to maintain their health and wellbeing and had access to healthcare services when required. People were offered a choice of home cooked food and drink that met their preferences and dietary needs.

Staff were kind and caring and treated people with dignity and respect and encouraged them to make choices and retain their independence. People were encouraged to maintain relationships with people who were important to them. Family and friends could visit at any time.

People and their relatives were involved in planning their care. Care plans were detailed and described how people wanted to receive their care. People took part in a wide range of activities and events at the home.

The provider was working towards meeting the Accessible Information Standards. Staff used a variety of communication methods to communicate with people which helped them to make decisions about their care.

People and relatives were offered opportunities to feedback their views about their care and this was used to improve the service.

Complaints procedures were available and displayed at the home. People knew who to speak to if they wanted to complain.

The registered manager understood their responsibilities under the Health and Social Care Act 2008, including submitting notifications of events as required to the commission.

We last inspected the service in August 2017 when we rated the service ‘requires improvement’ although we did not identify any breaches of regulation. The home has continued to make improvements and these now need to be embedded to ensure consistency of the delivery of the service.

At our inspection in October 2015 we identified the provider was not meeting the fundamental standards in a number of areas. We issued seven requirement notices and asked the provider to make improvements to the systems in place to keep people safe from harm and to prevent unlawful restrictions on people. Consent to care was not always sought In line with current legislation and guidance. Risk assessments had not always been completed and actions were not taken to mitigate risks. Staff training and medicines management required improvement and recruitment practices were not safe. Staff were not familiar with and able to apply the principles and codes of conduct associated with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The systems in place to assess, monitor and improve the quality and safety of the service were not operated effectively and records had not been accurately maintained.

At our inspection in December 2016 we found some improvements had been made. However, some concerns were on-going and new areas of concern were also identified.

Following the inspection, we issued four enforcement notices to the provider and registered manager for their on-going failure to meet four regulations in relation to the need for consent; safeguarding people from abuse; safe care and treatment and good governance and told them to take action to make the required improvements.

We also placed the service in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

During this inspection in July and August 2017, the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The previous registered manager resigned in January 2017. An acting manager [manager] was in place at the home and they had applied to register with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality 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.

We found the manager had a good understanding of their responsibilities in relation to meeting the Health and Social Care Act 2008 regulations. They had notified us appropriately of events required by law. The manager and provider had understood the seriousness of the concerns we highlighted during our previous inspection and had worked closely with other agencies for support and advice in how to make the improvements required.

People and relatives told us they felt the home was safe. Staff had received additional safeguarding training, understood how to identify abuse and explained the action they would take if they identified any concerns about people’s safety.

Individual and environmental risks relating to people’s health and welfare had been reviewed to identify, assess and reduce those risks. Up to date guidance was available for staff in how to support people in line with the risk assessments. Incidents and accidents had been investigated and learning shared with staff to reduce the risk of re-occurrence.

Systems were in place to ensure the management and administration of medicines, including controlled drugs, were safe. Some minor issues were identified which the manager said they would address. Staff received training to administer medicines and were assessed for competency.

Robust recruitment processes ensured that only suitable staff were employed. There were sufficient staff deployed to meet people’s needs during the day. Staff had time to sit and chat with people and support their emotional wellbeing. There were sufficient day staff deployed. However, night staffing roles did not reflect people’s night time care needs.

People were supported by staff, most of whom had received appropriate training, professional development, supervision and appraisal to enable them to meet people’s individual needs. Plans were in place to increase supervisions and appraisals for all staff.

The manager and staff understood and followed the principles of the Mental Capacity Act 2005 designed to protect people’s rights and ensure decisions were made in their best interests.

People were supported to maintain their health and well-being and had access to healthcare services when they needed them.

People enjoyed a variety of freshly cooked foods, prepared in a way that met their dietary needs. People received the support they needed to eat their meals.

Staff treated people with dignity and respect and ensured their privacy and independence was promoted. Staff interactions with people were kind and caring. Staff provided reassurance when people became anxious or upset. Friends and family were able to visit their loved ones at any time and felt welcomed by staff.

A part time activities co-ordinator had been employed who organised and provided opportunities for people to engage in social and physical activities.

People had detailed care plans which were regularly reviewed and updated when people’s needs changed. Some minor issues were identified which the manager told us they would address. People and their relatives, when appropriate, were involved in decisions about care planning.

Systems to monitor and assess the quality and safety within the home had improved. People and relatives were encouraged to provide feedback on the service provided through satisfaction surveys and informally during visits to the home.

Residents meetings took place and enabled people and family members to be kept up to date with improvements the provider was making. People and relatives confirmed they knew how to make a complaint and would do so if they needed to.

A range of audits were in place to identify shortfalls in service delivery. However, actions were not always recorded to ensure they had been followed through.

Staff meetings took place and staff felt well supported by the manager who was open and approachable. Staff were confident to raise any issues or concerns with them and were listened to and respected.

We recommend the provider reviews their night staffing roles in line with current good practice to better reflect the care needs of people during the night.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timescale.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

At our previous inspection in October 2015 we identified the provider was not meeting seven regulations. Systems and processes were not established and operated effectively to prevent abuse. Staff failed to recognise restrictive practice and to assess less restrictive options for people’s support. Risk assessments were not always completed and regularly reviewed and actions were not taken to mitigate risks. Staff training, and procedures regarding the administration of medicines were inconsistent and did not ensure the proper and safe management of medicines. Staff recruitment procedures were not established and operated effectively to ensure safe recruitment decisions. Consent to care was not always sought In line with current legislation and guidance. Staff were not familiar with and able to apply the principles and codes of conduct associated with the Mental Capacity Act 2005. The provider had not acted at all times in accordance with the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. People were deprived of their liberty for the purpose of receiving care without lawful authority. Systems in place to assess, monitor and improve the quality and safety of the service were not operated effectively, in particular in regard to people’s health and welfare. Records in respect of service users, persons employed and the management of the regulated activity were not accurately maintained.

Following the inspection, the provider sent us an action plan telling us the steps they were taking to make the improvements required. In July 2016 they sent us an updated action plan which informed us they had completed their actions or they were in hand. At this inspection, we found some improvements had been made. For example, staff training, supervision and appraisals had been completed. Staff recruitment procedures had been improved and all appropriate checks had been completed. Some improvements had been made to the safety of the environment.

However, on-going concerns remained in all other areas of the management of the home and in the care of people who lived there.

There was a registered manager in place at the home. A registered manager is a person who has registered with the Care Quality 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.

We found the registered manager did not fully understand their responsibilities in relation to meeting the Health and Social Care Act 2008 regulations. They had failed to notify the commission of events required by law. They had not understood the seriousness of the concerns we highlighted during our inspection.

Systems to monitor and assess the quality and safety within the home were not effective. Audits had not identified short falls in the management of the home and people’s care that we identified during our inspection. The provider’s action plan had not been adequately monitored for progress and to identify areas that still required improvement.

The registered manager and provider had failed to display their ratings in the home and on the website which we discussed with the registered manager on the second day of inspection. On the third day of inspection we noted the rating was displayed in the lobby but not conspicuously as required by law. The registered manager had not acted sooner on an action from an audit in November 2016 to do this. The website was updated by the provider following the inspection to display the rating as required.

Whilst people and relatives told us they felt the home was safe, we found on-going concerns. Staff had received safeguarding training, demonstrated an understanding of key types of abuse and explained the action they would take if they identified any concerns. However, whilst some incidents had been reported, other incidents, such as verbal abuse and intimidation between people, had not been identified as safeguarding concerns and had not been reported to the local authority safeguarding agency or to the Care Quality Commission as required by law.

Individual and environmental risks relating to people’s health and welfare were not always identified and assessed to reduce those risks. This was an on-going concern. Risk assessments were not always in place to provide detailed guidance to staff in how to protect people from harm. Incidents and accidents were not analysed effectively to learn lessons and reduce the likelihood of them happening again.

Systems in place to ensure the storage and administration of medicines, including controlled drugs, were not safe. Medicines records were incomplete and inconsistent. Staff were assessed for competency to administer medicines, however not all staff had received regular training to do so. This was an on-going concern.

Staff did not always follow legislation designed to protect people’s rights and ensure decisions were made in their best interests. The registered manager did not fully understand the Mental Capacity Act 2005 and allowed relatives, who did not have the legal right to do so, to make decisions about their family member’s care. This was an on-going concern. Whilst improvements had been made in relation to restraint, the registered manager had not ensured they supported a person to meet the conditions within a Deprivation of Liberty Safeguards authorisation.

There were insufficient staff deployed to meet people’s needs at all times. People were left unsupervised for long periods of time in communal areas during the mornings when staff were busy getting other people up. People’s emotional and social support needs were not always met as staff did not have time to sit and engage with them until later in the afternoons when other tasks had been completed. Some activities were planned throughout each week, however, it was noted there were no activities planned at weekends when there were less staff and more pressure on their time.

Most people were supported to maintain their health and well-being and had access to healthcare services when they needed them. However, we noted other examples of people not receiving the care they required in a timely way. Staff did not always act in line with the home’s ‘falls protocol’ or take appropriate action to request medical advice for people sustaining a head wound following a fall.

Staff treated people with dignity and respect and ensured their privacy was maintained most of the time. However, we observed some interactions and use of language, which was not meant unkindly, but that did not promote dignity and respect.

Initial assessments were carried out before people moved into Moorland House to ensure their needs could be met. Information was used to develop plans of care for people most of the time. However, this was not always the case and changes to people’s care needs were not always reflected accurately in their care plans. People’s care records were not always accurate or up to date.

People were supported by staff who had received an induction into the home and appropriate training, professional development, supervision and appraisal to enable them to meet people’s individual needs. Staff meetings took place and staff said these were helpful and enabled issues to be discussed. Staff felt supported by the management team and were confident to raise any issues or concerns with them.

People were supported to have enough to eat and drink and that met their specific dietary needs. People received individual physical assistance to eat when required and were provided with specialist equipment to enable them to maintain their independence to eat where possible.

The service was responsive to people’s needs and staff listened to what people said. People and, when appropriate, their families or other representatives were involved in decisions about their care planning.

Staff were caring and sensitive when people became anxious or upset, providing re-assurance and appropri

At this inspection we found the provider had taken steps to ensure staff had received appropriate supervision and training relevant to their job role. We gathered evidence against the outcome we inspected to help answer our one key question. Is the service effective?

Below is a summary of what we found. The summary is based on our discussions with the registered manager and from looking at relevant records. If you want to see the evidence supporting our summary please read our full report.

Is the service to be effective? We found the service to be effective as staff had completed a programme of training and supervision which meant they were trained and supported to carry out their duties.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking to people who use the service, the staff supporting them and looking at records.

Is the service safe?

People we spoke with told us that they felt safe. Safeguarding procedures were robust and staff understood how to safeguard people they supported.

People told us that they were treated well by staff and that they felt listened to and their wishes respected.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints and concerns.

Is the service effective?

People's health care needs were assessed with them, and they or their family were involved in writing their care plans. Specialist input, such as occupational health, was provided to support the planning and delivery of people's care.

People's care plans and risk assessments were updated regularly or when people's support needs changed.

Is the service caring?

We spoke with three people being supported by the service and asked their opinions about the staff who supported them. Feedback was positive. One person told us 'I'm well looked after and cared for, oh yes, I think so' and another said 'Staff are lovely.'

We observed that staff spoke to people with kindness and respect. It was clear that staff knew people well and responded to them positively when supporting them.

Is the service responsive?

People knew how to make a complaint if they were unhappy. We saw that the service had received one complaint and this had been investigated and responded to in line with the complaints policy.

The service worked well with other agencies and services, such as care management and GPs, to ensure that people received appropriate care and support.

We saw that when people's needs changed, the service responded in a timely way and communicated this to staff and other agencies.

Is the service well led?

The service had a quality assurance system and records showed that any identified issues, or opportunities for improvement, were addressed promptly.

Staff meetings took place which enabled staff to discuss and plan improvements within the service.

Staff received supervision and appraisals to identify training needs and monitor staff performance. However, these had not happened in line with the frequency in the company policy.

Staff told us that they were clear about their roles and responsibilities. They told us that they received training which supported them to carry out their roles.

We found that where people had capacity to be involved in their care, consent had been obtained about how they wished to be cared for and supported. Mental capacity assessments had been carried out to identify those people who did not have capacity to be involved in their care and support. Consent from relatives and health professionals had been sought in making 'best interest' decisions on behalf of those people who did not have capacity.

People's care and welfare needs were being met at the home. Assessments of people's needs had been carried out and care plans put in place to inform the staff team up on how to care and look after people.

There were sufficient numbers of staff employed to meet the needs of people accommodated at the home.

There were systems in place to monitor the quality of service provided to people living at Moorland House.

The manager had taken steps to improve record keeping following concerns identified through adult safeguarding proceedings. However, there were still some omissions in people's care records and gaps in recording.

We were assisted throughout the inspection by the home's deputy manager. We observed interactions between staff and residents during the inspection and spoke to some people living at the home. Owing to dementia these people were not able to tell us about living at Moorland House. We visited one person in their bedroom to look at how they were being cared for. We spoke with three members of staff and also met with an operations manager for the organisation.

We focused on how the care and welfare needs of three people were assessed, planned and delivered. We looked at their care plans and assessments and found that there had been significant improvements since the last inspection. Members of staff we spoke with also told us of improvements that had been made since the last inspection. We found that people were now protected from the risk of receiving inappropriate or unsafe care.

We, however, did have serious concerns about the way in which people's care was planned and monitored. The care records that we looked at for three people were out of date and proper steps to make sure care was both planned and delivered were not in place. We did observe though, that staff were attentive to people's needs throughout the inspection. They were also knowledgeable about people and there seemed good relationships between staff and people living at the home. We saw that activities took place to stimulate people.

We found that storage arrangements for controlled drugs did not meet current legal requirements and some improvements could be made concerning medication administration.

We found that staff were being recruited appropriately.