Moors Park House

Updated 31 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by 1 inspector and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Moors Park House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Moors Park House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information held in our systems and the information of concern we had received. We asked the local authority for feedback. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people at length and spent time talking to people and observing care delivery in communal areas over the 3-day site visit, including breakfast and lunch time observations. We spoke with 3 relatives, one visiting professional and 10 staff members including the registered manager and provider. We looked at 5 people’s care records in detail, sampled a further 11 people’s care records and looked at 19 people’s medicine records. We looked at records relating to safeguarding, accidents and incidents, quality assurance systems, recruitment and safety records, including records relating to premises and equipment.

Following our site visits we spoke with a further 9 relatives and 6 staff by telephone. We requested feedback from 11 health care professionals by email. We did not receive any responses.

Updated 31 August 2023

About the service

Moors Park House is a residential care home providing personal care and accommodation to up to 37 people. The service provides support to older people, the majority of whom are living with dementia. At the time of our inspection there were 34 people using the service. Accommodation is provided over two floors in an adapted and extended building. There were spacious communal areas for people to use including a lounge, conservatory, large dining room and library area.

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

Systems and processes were not operated effectively to protect people from the risk of abuse. The registered manager and provider consistently failed to share allegations of abuse and neglect with the local authority safeguarding team and failed to effectively investigate allegations of abuse, or act in line with their own safeguarding policy. Staff told us they did not feel confident safeguarding concerns were appropriately addressed.

Risks were not always safely monitored or managed, for example risks relating to bed rails, falls and eating and drinking. A lack of information and inconsistencies across people’s care plans meant people were at risk of harm. Medicines administrations systems were not well managed, and we identified a significant number of areas for improvement. Systems to ensure staff were recruited safely were not operated effectively and there were not always enough staff to meet people’s needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We found at least 14 people were living at Moors Park House without the capacity to consent to care and treatment. Capacity assessments had not been completed, and Deprivation of Liberty Safeguards applications had not been made. This meant people were being deprived of their liberty without legal authorisation.

Staff had not received sufficient training to meet people’s needs and there was a very low completion rate of core mandatory training including safeguarding and moving and handling. Staff had not completed sufficient training in meeting people’s specific individual needs such as dysphagia, diabetes and catheter care. Staff did not receive regular supervision.

People’s needs and choices were not always assessed. Some people’s care plans contained limited detail about their individual needs and choices, or how care should be provided in their best interest. People’s end of life care plans did not reflect their personal preferences. Some care plan's contained good information to help staff communicate with people, for example by reducing background noise and maintaining good eye contact.

People gave negative feedback about a minority of staff and often received support in line with staff routine and preference, rather than their own choice. Staff routinely used institutionalised language such as “singles” and “doubles” to describe the level of assistance people needed, and some concerns were raised about the way staff spoke with people. People and their relatives were not always involved in their care planning or their health monitoring.

Complaints were not recorded, and no regular reviews took place to ensure improvements were made following receipt of a complaint. Staff told us they had raised concerns, but they had not been addressed.

Quality assurance systems were not effective. Whilst some regular audits were being completed, they did not identify any of the concerns found at this inspection. No care plan audits were being completed. There were also no effective checks at provider level. Notifications were not made to CQC in line with legal requirements and there were no systems in place to ensure continuous learning.

We received mixed feedback about the culture of the service from staff and from people’s relatives. Staff told us they did not feel listened to, and this impacted upon the care people received because concerns were not addressed. Some people’s relatives told us they found communications received from the home hostile at times and concerns were not addressed. Other people’s relatives were more positive. One said, “The manager is very approachable. The culture is open and welcoming.”

Whilst some relatives had raised concerns with CQC, other’s felt confident their relative was safe. One relative said, “It’s comfortable and safe, I’m impressed.” Another relative said, “I think [relative] is safe. The staff are good, the manager is good, I’ve no concerns.” Some people’s care plans contained good information about how staff should use equipment to support them. Some staff were experienced in care and had completed training either some time ago at Moors Park House or in other care settings. This meant some staff did have enough knowledge to ensure people received safe care.

People were supported to eat and drink enough. One person told us, “The food is always good, I enjoy most of it.” Staff supported people to access healthcare services and people’s relatives felt confident staff sought input from other professionals in a timely way. One said, “I think staff would act on health needs promptly.”

Most people gave positive feedback about staff. One person told us, “The staff are all respectful”. Another person told us, “It’s pleasant here, the staff are all pleasant too.” We saw and heard kind, caring and supportive interactions between staff and people. People were supported to be active and to maintain relationships. On the second day of inspection, we saw an exercise session taking place in the lounge. We observed people were engaged with the activity and enjoyed taking part.

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 (15 March 2019)

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding people, the quality of care, communication, and the management of the service. A decision was made for us to inspect and examine those risks.

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.

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

The provider told us they were committed to addressing the concerns identified during this inspection. Prior to the end of this inspection, they had booked safeguarding and Mental Capacity Act training, and were taking action to update their policies and procedures.

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

Enforcement

We have identified breaches in relation to safeguarding people, safe care and treatment, person-centred care, consent, receiving and acting on complaints, staffing, fit and proper persons employed and good governance at this inspection. We issued 7 Warning Notices.

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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.