CQC report explained · a residential care home
What the CQC found at Moorhaven
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and staff knew how to recognise and report abuse. Medicines were given safely, although some records of prescribed creams were still not complete.
- Effective?
- Good
- People received suitable food, healthcare and support from trained staff. Some record keeping about mental capacity decisions did not fully follow legal principles.
- Caring?
- Good
- This question was not inspected or rated during this focused inspection.
- Responsive?
- Good
- This question was not inspected or rated during this focused inspection.
- Well-led?
- Good
- Quality checks and management systems had improved and were identifying shortfalls. The home was no longer in breach of Regulation 17.
What inspectors found, August 2022
Rated Good; inspectors found safe, kind care, but some medicine and legal-record keeping still needed monitoring.
This was an unannounced, focused inspection on 20 July 2022. Inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They observed care and checked care plans, staff files, audits and safety records.
The home was rated Good overall, with Good ratings for Safe, Effective and Well-led. People generally felt safe, received their medicines and healthcare, had choices about daily life and meals, and were treated kindly. The home had improved since the previous inspection, when it was rated Requires Improvement.
Inspectors found the home was no longer in breach of Regulation 17 about good governance. Some recording issues remained, including records for prescribed creams and some mental capacity decisions. The garden areas also looked neglected, and one visitor raised concerns about staffing levels.
People felt safe
People appeared comfortable with staff and said they felt safe. Staff knew how to report safeguarding concerns.
“People felt safe at the home and looked comfortable and relaxed with staff who supported them.” from the report
Healthcare support
Staff worked with healthcare professionals and followed their recommendations. People could access healthcare when they needed it.
“People had good access to healthcare professionals to make sure they received the care and treatment they required.” from the report
Choice and independence
People could follow their own routines and make choices about food, activities and daily life. Staff supported people without taking over.
“People were able to make choices about their day to day lives.” from the report
Improved management
The home had stronger quality checks and clearer management arrangements than at earlier inspections. Feedback was collected and used to make changes.
“The provider had robust quality assurance systems.” from the report
Medicine records
needs fixingPrescribed creams were being used more safely, but records did not always show when they had been applied. The manager said this would continue to be monitored.
“There were still some issues with the recording of when creams had been applied but the registered manager gave assurances that they continued to monitor this.” from the report
Mental capacity records
needs fixingStaff understood how to support people's rights, but some records did not fully follow the principles of the Mental Capacity Act.
“However, some record keeping was not in accordance with the principles of the law.” from the report
Outside areas
minorThe gardens had seating but were not well maintained. Staff said they hoped to improve them with people and volunteers.
“People had access to outside space. Garden areas offered seating but looked neglected.” from the report
Mixed views about staffing
minorMost people and visitors thought staffing was adequate, and inspectors did not see people waiting for long. However, one visitor felt there were not enough staff and that this could affect care.
“I don't think there are enough staff, but I know everywhere is struggling. I think it must have an impact on the care.” from the report
- 01How do you now check and record every application of prescribed creams?
- 02What changes have you made to ensure mental capacity decisions are recorded in line with the law?
- 03What is the timetable for improving the garden areas, and how will residents be involved?
- 04How do you decide how many staff are needed in each area, and how do you respond when staff are busy?
- 05How do your current audits identify and fix any new shortfalls in care planning or record keeping?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used earlier ratings for questions not inspected. This explanation was written from the published report of 6 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found progress in mental capacity care and infection control, but quality checks were still not reliable enough.
This was a targeted inspection on 17 December 2020. Inspectors looked at specific concerns about healthcare monitoring, the Mental Capacity Act and how the home was managed. They also checked infection prevention and control.
People were generally happy with their care. Staff had received infection-control training, and inspectors were assured that the home was using protective equipment, testing and hygiene measures safely.
Improvements had been made since the previous inspection. Staff had a better understanding of mental capacity law, and the home had an action plan and more management support. However, records did not always show that healthcare referrals were followed up, and the quality monitoring systems had not been in place long enough to show that improvements would last.
The overall rating remained Requires Improvement. This was a targeted inspection, so the ratings for Safe, Effective and Well-led were inspected but not changed or rated again. The home remained in breach of Regulation 17 on good governance.
Infection control
Inspectors were assured that the home had suitable measures to prevent and manage infection, including safe use of protective equipment and access to testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Mental capacity practice
Staff had received extra training and were using capacity assessments and best-interest processes more appropriately. This earlier breach was no longer continuing.
“At this inspection we found improvements had been made in staff understanding and the implementation of good practice in this area.” from the report
Management support
The provider had added resources, changed the management team and introduced an improvement plan. Staff said management was approachable and communication had improved.
“Additional support from the provider, and a change in the management team, had led to a greater understanding of quality performance.” from the report
Healthcare follow-up records
needs fixingRecords did not always show that health complaints and professional referrals had been followed up. Senior staff did not know what had happened in the examples inspectors checked.
“Record keeping was not always adequate to monitor and review the support people received to maintain their health.” from the report
Quality systems not yet reliable
seriousThe provider's quality checks had improved but had not been established long enough to show that they would continue to work. They also failed to identify two healthcare follow-up issues found by inspectors.
“Therefore, we were unable to assure ourselves that these improvements would be sustained.” from the report
- 01How do you now record and check that every healthcare referral and health complaint has been followed up?
- 02What evidence can you show that the quality-monitoring improvements have continued since this inspection?
- 03Who is currently managing the home, and what is the plan for appointing and registering a manager?
- 04How are staff supported to involve people in decisions when they cannot communicate their choices verbally?
- 05What activities and daily engagement are now offered to support a person-centred approach?
This was a targeted inspection of specific concerns about healthcare monitoring, the Mental Capacity Act, management and infection control; it did not reassess all five key questions, so some ratings carried over from the previous inspection. This explanation was written from the published report of 12 January 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Moorhaven
5 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2021Requires improvementstayed Requires improvementSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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