Hunters Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Accidents and incidents were documented and investigated by the management team. Actions were identified to reduce the risk of reoccurrence. Numerous robust systems were in place to identify and share lessons learnt with the staff team through meetings, on a one-to-one basis or through a group supervision. Learning was discussed at provider level, for example by sharing this with other services. This was also shared in relatives and residents meeting.

Evidence of lessons learned identified through quality monitoring systems and shared with the team included areas such as medicine errors, catheter care, pressure ulcers and risk of choking.

An example we were given was; by looking at trends from accidents, incidents and falls, it was identified a change in staff start times in the mornings was needed. This was implemented to improve the support of people’s morning routine requirements.

The analysis incidents between February and April 2025 identified an increase in falls. This led to the introduction of various physical activities, including balloon tennis, outdoor games, gardening, outings, physiotherapy sessions, and weekly chair-based fitness classes. One specific incident was used as a training example and discussed in staff, resident, and relative meetings.

Over three months, these interventions resulted in a 40 percent reduction in falls, improved resident confidence and sleep, and strengthened trust among people and families in the service’s reviews processes and considering going the extra mile to support people. Key lessons included the importance of early identification, tailored prevention strategies, and the role of consistent exercise in enhancing mobility, nutrition, and hydration.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were assessed face to face prior to moving to the service to ensure their needs could be safely met. Records showed people were referred to other healthcare professionals when needed. There were regular reviews by either a GP or advanced nurse practitioner and nurses told us it was easy to contact a health professional for advice between visits.

Staff told us they worked well with health and social care professionals and had developed good working relationships.

Feedback from professionals in relation to their working partnership with the service was very positive.

One health professional told us, “The team are very proactive here. They refer direct to the tissue viability nurse, the speech and language therapist and the physiotherapist. The referrals happen quicker because the staff know people really well and know when a referral is needed.”

The registered manager told us they have been attending training sessions to introduce a virtual ward system in the service with the aim to reduce hospital admissions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

People felt safe living at the service and if there were situations when they did not, they would know who to speak with. Comments included, “I feel safe living here; definitely” and “Yes; we do feel safe. We have no problems.”

One relative told us, “My [relative] does feel safe and always speaks to whoever is in charge when needs to.”

Systems were in place for safeguarding concerns to be managed and reported to external agencies. We discussed some specific concerns related to 2 people with the registered manager and they were able to provide oversight of these, actions which were taken at the time and details of partnership working with the families or healthcare professionals. They maintained records, which enabled them to provide historical details in response to our queries about any safeguarding incidents involving staff.

Staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). Where people had a Deprivation of Liberty Safeguards (DoLS) in place, the management oversaw authorisations to ensure they were in date and that any imposed conditions were being met. Information about any DoLS conditions were recorded in people’s care records and included on a tracker.

The service evidenced through a case study the positive impact on a person following their support through a safeguarding process. They told us the person fed back they were pleased they had the chance to regain their independence and safety. They were more orientated and less distressed, attended activities, residents meeting, living their life at full as much as possible and at times going out with their family.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had been assessed for risks such as skin integrity, choking, falls and malnutrition. When risks were identified, the care plans informed staff how to reduce the risks and how to keep people safe. Examples included how to reduce the risk of people choking by ensuring they were supported to be in the correct position when eating and drinking, and following any advice provided by healthcare professionals. When people were assessed as being at risk of falls, advice was sought from the falls team where appropriate.

Some people were at risk of skin damage. Care plans informed staff how to reduce the risk, including how often staff needed to support people to change position and any pressure relieving equipment in use. Air mattresses we looked at were set correctly and records showed people had their positions changed in line with care plan guidance.

People were enabled to take positive risks. The service evidenced through a case study the positive impact a person following support in this area. They experienced significant changes in health including becoming unable to eat and drink orally and this loss of independence had a profound emotional impact. The person expressed a strong desire to prioritise quality of life over clinical caution and resume a level of oral intake. They were supported with this through involvement of a multi-disciplinary team. The service told us this case highlighted the importance of person-centred care, risk-informed decision-making, and empowering people to make choices that preserve dignity and maintain the best possible quality of life.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Regular health and safety checks of the environment and any required equipment had been completed and were overseen by the maintenance team. The provider was also carrying out periodic audits of the service to ensure compliance with legal requirements and policies and procedures.

One person said, “The maintenance man is brilliant. He comes and does all his checks regularly. They even brought our furniture here for us when we moved in.”

Another person told us, “The maintenance people are so kind. I know they are not our carers, but they are so kind. On my way to breakfast this morning, I was trying to tighten my belt and the maintenance seen me, took my belt and before I finished my breakfast I had my belt back which I was very impressed.”

The service evidenced through cases studies the positive impact on people following improvements made to the environment. For example, the refurbishment of the kitchenette in the Memory Lane unit, provided people with a more elegant, safe and purpose build dining room which reduced the risk of scalding / burns and also improved their experience of dining. Another example was the improvement work to the dining and lounge doors which had not only improved the environment for people but have also enabled them to have the independence back by being able to access the garden without support but at the same time to remain safe.

During our site visit we observed a conversation between a person living at the service and the registered manager regarding plans to make changes to the windows in the building. The registered manager listened to the person’s views and invited them to join the contractors when they came, recognising the person’s knowledge in the areas.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We received mixed feedback for people and relatives in relation to staffing levels and their responsiveness. While most people and relatives told us they felt there were enough staff on duty and if they used their call bell, staff usually responded within an acceptable timeframe, some felt improvements could be made in these areas. For example, one person said, “I only really use my buzzer at night because it’s dark. They come quite quickly; sometimes I have to wait a bit.” One relative told us, “Sometimes [person] feels it takes a while to respond to a buzzer but someone always does and maybe they have to prioritise sometimes.”

Systems were in place to review staffing levels based on the provider's dependency tools and through monthly staffing reviews. Staffing levels and rota management were also monitored at provider level. Information was provided to us about how call bell response time were monitored and how issues identified through monitoring systems were addressed. Staff did not raised concerns in relation to staffing levels. During our site visits we did not observe significant delays in call bells being answered.

The service promoted a whole home approach, meaning, for example that staff who were not directly involved in the delivery of care provided support for example at mealtimes, with activities or in case of emergencies. One staff member told us they used a whole home approach where everyone was helping each other and when someone needed something everyone was available to help which made things easier.

Recruitment checks were completed before staff were employed. The service was not using agency staff and had not done so for a long time. They had a pool of their own bank staff and used regional bank staff which meant that people were supported by staff with the same level of training and awareness of provider values. Staff were provided with an induction when they started their employment. We observed care staff and nurses receiving induction training during our site visit.

Mandatory training was being completed by staff as well as additional training to support with people’s individual needs. Dementia training was provided to all staff working in the home, regardless of the department they worked in to enable understanding and support people through a whole home approach. Staff had their competencies check in different areas of care delivery such as moving and handling and clinical tasks.

Staff received supervisions and appraisals from their line managers and told us they felt supported by the management team.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected by the prevention and control of infection. The home was clean. We observed that some attention was required in relation to the décor in some areas of the home such as communal areas and toilets. A refurbishment plan was in place for the service, and we saw from the records we looked at, that the details of this had been shared with people and relatives.

The service had an infection prevention control champion in place. They told us that part of their role was to carry out observation such as people leaving gloves on the floor, hair, nails, jewellery, preventing infection spreading and donning and doffing of protective equipment.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff who were responsible for managing medicines were aware of safe practice, had completed training and had their competence assessed and regularly reviewed. We observed one member of staff supporting people with their medicines. They did so professionally and with a calm manner; they did not rush the person and made sure they had a drink.

Medicines were stored, administered, recorded and disposed of safely. Robust processes were in place to ensure people received their medicines in line with their prescriptions, including those medicines that were time specific. Regular stock balance checks were carried out.

Some people were prescribed additional medicines on an as required (PRN) basis. PRN protocols were personalised and informed staff of alternative steps to take prior to resorting to the use of medicines. One person said, “I have pain and they [staff] give me regular pain killers. The nurse did say the other day ‘let me know if you need anything stronger’.”

We saw people had their medicines regularly reviewed and the registered manager told us how the service was working to reduce reliance on some medicines where appropriate. For example, they told us how the staff were using prune juice as a non-medicinal intervention.

Some people had been assessed to manage their own medicines. One person told us, “I look after my own tablets. The staff count them every Sunday to check them. I keep them in a locked drawer and the key is hidden. I know I have to keep them safe."