Moonstone Care UK was rated Requires Improvement overall at its first inspection, with five breaches identified across recruitment, risk and medicines management, staffing deployment, person-centred care planning, and governance. Despite these systemic failings, people and relatives consistently described staff as kind, caring and respectful, and praised the approachable registered manager.
Concerns (9)
critical
Staff training
: “References were not always verified or appropriate, for example one reference was written by a relative of the applicant.”
criticalStaffing levels: “Records of daily logs reviewed showed two staff did not always turn up to provide care. We could not be assured that people's needs were always met”
criticalMedication management: “People were at risk of not receiving their medicines as prescribed. Medicine administration record charts and information about medicines were inconsistent and unclear”
criticalCare planning: “Care plans were not always consistent... in one care plan it stated the person was fully dependent on assistance and bedbound, yet another plan for the same person stated the person did not require any help”
criticalPerson-centred care: “care plans were not person-centred, and people's needs were not always met. This was a breach of regulation 9 (person- centred care)”
criticalGovernance: “Systems and processes for managing the service were not robust enough to ensure issues found during our inspection had been identified and addressed.”
criticalOther: “risks related to pressure ulcers, choking or entrapment from bedrails were not considered. This put people at risk of harm”
moderateIncident learning: “evidence of learning from incidents and accidents were not recorded”
moderateRecord keeping: “The service did not always maintain accurate care records relating to people using the service and staff recruitment records.”
Strengths
· People and relatives reported feeling safe with care staff who treated them with dignity and respect
· Staff received training and supervision and felt supported by the registered manager
· Good infection control practices with adequate PPE and regular COVID-19 testing
· Cultural and religious needs of people were met
· Registered manager described as approachable, supportive and good at listening to staff
Quality-Statement breakdown (20)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and management; Using medicines safely; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood