Moor Park House Limited

Updated 8 January 2021

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 Care Act 2014.

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 team was made up of one inspector and a pharmacist specialist.

Service and service type

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

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

The first day of this inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection-

We spoke with four relatives about their experience of the care provided to their loved ones. We spoke with six members of staff including the registered manager, nurses, senior care workers, and care workers. We carried out observations of care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included five people’s care records and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 8 January 2021

About the service

Moor Park House Limited is a 54 bedded purpose-built home. The home provides personal and nursing care for young adults and older people, specialising in care for people needing support with complex needs, physical disability and acquired brain injury. There were 52 people living at the home when we visited.

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

The service was not always safe. At the last inspection we recommended that the provider implement systems to show an audit trail of accidents and incidents. At this inspection we found this had not been implemented effectively. We could not be assured that lessons had been learnt to prevent similar incidents reoccurring. We found medicines records were not always managed effectively. Systems and processes in place were not robust enough to ensure medicines policies and practices were consistently implemented. People did not always have risks to their personal safety identified and recorded. When they had been identified, control measures were not always documented to mitigate the risk. Staff were able to tell us about the risks to people and knew how to support people to minimise the risks.

The service was not always well led. The registered manager had not operated effectively systems to assess, monitor and improve the service. Some records relating to care and the management of the service were either incomplete, inaccurate and/or not kept up to date. The issues we found were not picked up by the auditing systems in place. This could have compromised the quality and safety of the service provided. Staff told us they felt well supported in their role. People we spoke with told us that they felt their loved ones were well cared for.

We found the management team receptive to feedback and keen to improve the service. The registered manager worked with us in a positive manner and provided all the information we requested. Additionally, they responded promptly to our concerns during and after the inspection.

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 7 July 2018).

Why we inspected

The inspection was a targeted inspection prompted in part, due to concerns received about medicines and documentation. A decision was made for us to inspect and examine those risks.

We inspected and found there were concerns with oversight of risk and quality assurance, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well led.

The ratings from previous comprehensive inspections for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

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 Moor Park House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to good governance at this inspection.

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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.