Last updated: 9 February 2026
"Staff enjoy a positive team culture with plenty of stimulating activities, but poor risk assessments and ineffective audits undermine safety."
People’s individual risks and environmental risks were not always assessed and mitigated, for example risk assessments were either not in place or did not contain enough information; only 1 of 8 had bed rail assessment.
Staff were positive about working at Moundsley House, one staff member told us, 'We do a lot of teamwork, we are here to give a quality of care the residents deserve and need and we respect their wishes'.
People told us there were enough staff to care for them and we saw there were sufficient staffing levels on both days of our assessment to meet the needs of the people who used the service.
Training records showed that some staff had received training however, not all staff had completed or undertaken refresher training on safeguarding.
Staff told us leaders were visible and the registered manager was approachable and supportive, but audits and checks were not always effective and had not identified concerns, resulting in a breach of Regulation 17.
We saw the activity team providing people in the communal areas with plenty of stimulating activity including keep fit, games and music; one person told us 'There’s lots of activities'.
Risk assessments are often missing or not detailed enough for things like bed rails and wheelchairs without footrests, making care less safe.
We looked at 8 peoples records, only 1 person had a risk assessment in place to determine bed rails were safe to use.
Managers checks and audits miss safety problems or do not fix them quickly enough.
Whilst there were a range of audits and checks in place to assess the quality and safety of the service, we found that these were not always effective and had not identified some of the concerns we found in relation to safe environments, risk assessment and medicines management.
Some staff lack refresher training on spotting and reporting abuse.
Training records showed that some staff had received training however, not all staff had completed or undertaken refresher training.
AI Generated
Last inspected: September 2024
Management Quality
Well-led: Good
Direct feedback from current and former employees

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