CQC report explained · a residential care home
What the CQC found at Moulsham Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found some safety and leadership issues but care was generally kind and supportive.
Inspectors visited Moulsham Home unannounced on 20 November 2023 to check the safety and management of the service. They spoke with relatives, staff, and reviewed records.
They found the home provided a safe, comfortable environment where people’s independence was encouraged. Staff supported people well and were trained in medicines and safeguarding.
However, there were concerns about some recruitment checks, incomplete risk assessments, and gaps in medicines records. The management’s quality checks did not always spot these problems.
The home had a calm atmosphere and good relationships between staff and people living there. The manager was open to learning and working with others to improve care.
Supportive environment
People lived in a homely, well-equipped place that met their needs and promoted independence.
“Care and support were provided in a safe, homely, well equipped, well-furnished environment which met people's physical and sensory needs.” from the report
Staff training and knowledge
Staff received training in autism, learning disabilities, medicines, and safeguarding and understood how to support people safely.
“Staff had received training in safe medicines management and were assessed as competent before administering medicines and knew how to report errors.” from the report
Positive culture
The home had a calm atmosphere with good relationships between people and staff.
“There was a positive culture at the service. The service felt relaxed and had a calm atmosphere.” from the report
Infection control
Staff followed good infection prevention practices and the home was clean and well maintained.
“We were assured the provider was promoting safety through the layout and hygiene practices of the premises and ensuring infection outbreaks could be effectively prevented or managed.” from the report
Risk assessments not always updated
needs fixingSome risk assessments were out of date, including after a recent fall, which could put people at risk.
“A person who had recently had a fall did not have an updated risk assessment.” from the report
Incomplete end of life plans
minorEnd of life wishes were not fully recorded for all people, limiting personalised care planning.
“There was limited information in the support plans we reviewed relating to people's end of life wishes.” from the report
- 01How do you ensure all staff recruitment checks are fully completed and verified?
- 02Can you explain how you manage and record the use of 'when required' medicines?
- 03How often are risk assessments reviewed and updated, especially after incidents?
- 04What systems do you have to learn from incidents and improve care?
- 05How do you involve people and their families in planning for end of life care?
This was a focused inspection of Safe and Well-led only; the other ratings carry over from 2017. This explanation was written from the published report of 1 December 2023 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, July 2020
Moulsham Home was inspected but not rated; inspectors found enough staff, good infection control and care that respected people's choices, but safeguarding procedures needed clearer guidance.
This was an unannounced, targeted inspection on 23 June 2020. Inspectors followed up concerns about staffing, safeguarding and infection control. They inspected from 6am, spoke with 10 staff members and observed care.
Inspectors found enough staff to meet people's needs safely. Call bells were answered promptly, people could choose when to get up, and staff knew their care preferences. The home was clean, and staff used protective equipment appropriately.
The provider's safeguarding policy needed clearer instructions about reporting and escalating concerns. The inspectors made a recommendation for the provider to strengthen staff knowledge and procedures. No new concerns about harm were found during this visit.
This was a targeted inspection, so the service was not given a new overall rating. The previous overall rating was Good, published in September 2017. The Safe question remained Good from the previous inspection but was marked inspected but not rated here.
Enough staff
Inspectors found enough staff to provide care safely. Call bells were answered promptly.
“Enough staff were available to provide care to meet people's needs safely.” from the report
Respect for choice
People were supported to choose when to get up, including staying in bed if they wished. They were also offered choices at breakfast.
“One person wanted to stay in bed and staff supported them to do this.” from the report
Clean and controlled environment
The home was clean, laundry processes were organised, and staff had protective equipment and hand-washing facilities.
“We found people were protected from the risk of acquiring infections and the service was clean.” from the report
Staff knowledge
Staff could explain people's needs and the process for separating clean and soiled laundry.
“During the inspection call bells were answered in a timely manner and staff were knowledgeable about people's needs and how they wanted to be cared for.” from the report
Safeguarding policy needed clearer guidance
needs fixingThe policy did not clearly explain how staff should escalate concerns or how staff involved in complaints or safeguarding matters should be supported and managed. Inspectors recommended getting advice to strengthen this area.
“The policy the provider had in place was generic and required further clarification to ensure escalation processes were clear to staff.” from the report
- 01What changes have you made to the safeguarding policy since this inspection?
- 02How are staff trained to recognise, report and escalate safeguarding concerns?
- 03How do you make sure staffing levels remain sufficient at all times, including early mornings?
- 04How do you check that people can choose when to get up and what they want for breakfast?
- 05How are clean and soiled laundry kept separate, and how is staff use of protective equipment checked?
This was a targeted inspection of specific concerns about staffing, safeguarding and infection control; it did not assess the whole service or change the previous ratings. This explanation was written from the published report of 17 July 2020 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 Moulsham Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2020Inspected but not ratedSafe: Inspected but not rated
- September 2017Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 12 September 2011.
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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