Moors Park House

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

We identified one breach of regulation. Governance processes were not effectively operated. There were no effective investigations into allegations of abuse. Where audits were completed, they were not thorough or effective. There was no complaints process in place or any oversight of DoLS applications or conditions. The service development plan was not effectively implemented, and provider oversight was not effective. Feedback about the leadership was mixed, and we found leaders did not have the skills, knowledge or experience to lead effectively. Service improvement plans were not effectively implemented to drive improvement. Some staff told us they had seen improvements over the previous 12 months, and that communication and staff morale had improved.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback about the leadership of the service. Some staff told us they had seen improvements over the previous 12 months, and that communication and staff morale had improved. One staff member said, “I like working here, it’s very homely, most people help each other, and I like the atmosphere”. Other staff said that whilst they felt able to raise concerns with the manager, they didn’t feel sufficient action was taken.

There were processes to involve staff in the service development. Staff meetings were held where they could contribute ideas and suggestions. The local authority had developed a service improvement plan to drive improvement, however, the provider had not kept this up to date or acted on recommendations in a timely manner.

Senior staff did not benefit from high quality leadership or have access to appropriate support or development in their role. This meant senior staff, whilst working hard to develop the service, were not always able to do so effectively. Leaders did not always fully understand their role or demonstrate integrity or openness when addressing concerns.

Leaders did not lead effectively. There were not always clear lines of responsibility to ensure staff understood their roles. The provider failed to identify poor culture or poor practice and did not effectively address all the breaches of regulation identified at our last inspection.

Most staff told us they felt comfortable speaking up, however, a minority felt reluctant to do so due to a lack of confidentiality and previous failure to act on concerns.

There was a whistleblowing policy in place. There were policies in place relating to the Duty of Candour detailing the providers responsibilities in the event something goes wrong, however, because there was a lack of formal investigation into concerns raised or incidents recorded, it was not possible to establish this duty had been fulfilled.

Whilst some staff reported improvements to the culture of the service, others felt there were still barriers in place which meant equality, diversity and inclusion were impacted. For example, some staff felt that there was a culture of bias and that friendships within the staff team impacted working practices. We heard that some staffs own health had been adversely impacted by working practices at the service.

There were no systems in place for leaders to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion.

Senior staff told us they felt confident governance processes were in place, and that they understood their role and responsibilities, but had not always had time to complete them fully. We found significant gaps in audit processes which meant key information had been missed, including incidents and allegations of abuse. This meant data or notifications were not always submitted to external agencies as required. Staff acknowledged that whilst they had completed some routine governance, it had not been consistent.

Governance systems were not effective in identifying regulatory breaches or areas for improvement. There were no effective investigations into allegations of abuse. Where audits were completed, they were not thorough or effective. For example, accident and incident audits did not include all incidents recorded or any detailed analysis of them. Because risks weren’t always identified through the governance process’, there was a lack of action taken to mitigate future risks. Whilst some individual care plans were reviewed, there was no oversight of completion of care plans and risk assessments, and no oversight of Deprivation of Liberty applications. Since our last inspection the provider had commenced governance visits, however, they had not been fully completed and were not effective.

People received care from a service that worked in partnership with other health and social care professionals. When we spoke with people and their relatives, no concerns were raised about access to other health professionals.

Leaders told us they worked openly and transparently with partnership services, however, we found not all information had been shared appropriately. Leaders told us they hadn’t accessed local networks or forums to drive innovation but intended to do so in the future.

Partners told us that whilst staff demonstrated an intention to work openly and in partnership, the lack of governance structures meant it was at times hard to do so. Where leaders told partnership agencies they would take action, they did not always do so.

There were processes in place to work in partnership with other healthcare professionals to escalate concerns or risk to people as required. We saw from records and feedback that working relationships were in place with the local district nursing team, GPs, social workers and the safeguarding team. However, these processes were not always operated effectively.

A service improvement plan had been provided by the local authority quality assurance team, who had worked with the service to support improvements since our last inspection. However, we found that insufficient improvements had been made since the last inspection and the service remained in breach of regulations.

The current processes in place for governance and auditing were not fully effective. There was no system to investigate and learn from complaints, and a lack of monitoring of risks to people’s health safety and welfare placed them at risk. Staff record keeping was not always consistent or accurate, for example in relation to pressure area care, and this had been highlighted during staff meetings. However, it was evident that improvements were still required.