Hunters Moor Neurorehabilitation 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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At this inspection the service was in breach of legal regulation in relation to people’s safe care and treatment

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not consistently demonstrate a proactive learning culture. Although staff recorded incidents and accidents into the provider’s internal electronic reporting system, leaders did not robustly investigate them or consistently analyse trends. Leaders could not provide evidence of structured review or demonstrate how learning had been embedded into practice, therefore, limiting opportunities to reduce risk and improve the quality of care people received.

People who use the service and their relatives told us concerns were not always acted upon effectively. One relative said, “If something changes, unfortunately it does not last long”. Another told us, “On the face of it, it looks like change has happened, but then when you sit and watch, you realise that it’s very soon forgotten”. One person using the service told us, “Raising concerns and things being actioned is hit and miss”.

This confirmed our findings that improvements were not sustained.

Staff feedback also reflected concerns about the lessons learned process. One staff member told us, “The process for lessons learned is not yet in place”. This demonstrated that systems for structured learning were underdeveloped at the time of inspection.

Leaders acknowledged learning culture was an area of concern and had plans in place to address it, however, systems to consolidate learning and embed change had not been effectively established at the time of the inspection.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not consistently involve relatives in care planning. Relatives reported having to actively pursue information to understand care and rehabilitation plans. One relative told us, “It’s taken at least two months for me to be able to find out exactly what the plan is”. Another relative said, “Because my relative is not capable of doing certain things for themself, I’ve really had to push for me to be involved on their behalf”.

During our review of records, we identified that admission planning lacked sufficient structure and documentation. Initial assessment documentation did not always provide holistic information about people using the service. This increased the risk of staff not having sufficient information to deliver safe, personalised care. These weaknesses increased the risk of fragmented care, and we could not be assured that transitions were consistently safe and well managed. Leaders acknowledged that discharge pathways required improvement, however, this remained an area for improvement at the time of our inspection.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always protect people from avoidable harm. The provider did not always share concerns quickly and appropriately.

Safeguarding systems were in place; however, governance oversight did not consistently ensure concerns were robustly reviewed for themes, trends or learning. This reduced assurance that risks were proactively identified and mitigated. Staff lacked understanding of their reporting responsibilities to the Care Quality Commission (CQC) and did not consistently escalate concerns. Where concerns were escalated, the provider did not consistently provide appropriate and timely feedback to CQC when requested.

One relative told us, “I’ve raised a number of safeguarding alerts in recent months, my concerns seem to just be brushed under the carpet”.

Although staff had training in Safeguarding and the Mental Capacity Act, the provider did not consistently apply the Mental Capacity Act (2005) when supporting people who did not have capacity. Records did not always evidence capacity assessments, best-interest decisions or consideration of the least restrictive option where restrictions were in place. It was not always clear whether Deprivation of Liberty Safeguards (DoLS) had been fully considered or reviewed. This created a risk that decisions affecting people’s liberty were not consistently lawful or proportionate. Best-interest decisions were absent for a significant proportion of people who lacked capacity, reducing assurance that decisions were lawful and appropriately documented.

Leaders told us that frequent management changes had resulted in staff having an inconsistent understanding of safeguarding escalation and notification requirements, including to the CQC. This affected the provider’s ability to provide accurate and timely information.

Leaders recognised these gaps and described plans to strengthen safeguarding knowledge and escalation processes. However, at the time of inspection, safeguarding oversight was not effective.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was safe, supportive and enabling.

Risk assessments and care plans were present but were not consistently reviewed or updated when people’s needs changed. We identified incomplete allergy information in some records, reducing assurance that staff managed known risks safely.

Records did not always demonstrate that identified risks were linked to clear actions. For example, one person’s care plan recorded low mood as a high-risk score; however, there was no documented evidence of psychological input or mitigation strategies. This limited assurance that emotional risks were actively managed. Similarly, repositioning people to prevent pressure damage and the use of specialist equipment, were not consistently implemented or monitored. This reduced assurance that identified risks were reliably managed.

However, we observed positive examples of proportionate risk-taking in therapy sessions. One person told us, “The physiotherapy is the highlight of this place as I can stand again now, following a period of being unable to walk”. Therapy staff had supported this person to stand and mobilise safely, which demonstrated effective and enabling risk management.

Overall, risk management was inconsistent. Although there were examples of good practice, systems did not reliably ensure holistic, person-centred and timely risk mitigation.

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology consistently supported the delivery of safe care.

During inspection, we identified multiple environmental hazards in areas used by people using and visiting the service. These included ligature risks, unsecured sharp tools, broken fencing which led towards a public road. In addition, unstable materials, broken patio slabs, stagnant water, decaying waste and overgrown vegetation. This meant people had restricted access and unsafe seating. These hazards posed foreseeable risks of injury, falls, infection and harm. Inside the premises we also identified missing window restrictors and broken fixtures requiring repair.

An environmental audit completed prior to our inspection recorded the external environment as “100% well maintained and free from hazards.” This did not reflect the actual environment. Several hazards appeared longstanding, which demonstrated that the provider’s systems had not identified or addressed risks.

Although leaders took feedback on board immediately and acted promptly to mitigate risks identified during inspection, this reactive response did not compensate for the significant failure of systems to proactively detect and control hazards.

As a result, people were exposed to avoidable environmental risks, and the provider could not demonstrate reliable oversight of premises safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People, relatives and staff raised concerns about staffing levels and responsiveness. One person told us response times could be, “20 minutes on a bad day and five to ten minutes on a good day”. During inspection, we observed call bells ringing for several minutes before staff responded. These delays meant people did not always receive timely assistance, increasing the risk of unmet care needs, avoidable discomfort and deterioration in people’s health and wellbeing.

Staffing levels and staff deployment did not consistently ensure people received agreed care and clinical interventions in a timely way. Professionals and staff described examples where agreed clinical interventions were not consistently implemented or monitored due to insufficient staffing.

Relatives described occasions where people’s basic care needs were not met promptly. One relative told us, “My relative was asking for their pain relief for nearly two hours nobody seemed to care”. Delays in care and support, increased the risk of harm, distress and loss of dignity for people using the service.

The service relied heavily on agency staff. Relatives and people using the service reported that agency staff were not always familiar with people’s needs. One person described the service as, “Agency staffed and understaffed”. Leaders acknowledged reliance on agency cover and recognised this affected consistency and continuity of care.

Mandatory training was largely up to date and specialist tracheostomy training had been delivered. Therapy staff demonstrated skilled and compassionate care, and some staff reported improvements in staffing levels compared with previous months. However, staffing levels, skill mix and continuity were not consistently sufficient to ensure people received safe, timely and person-centred care. As a result, people remained at risk of delays in receiving care and support, which could lead to avoidable discomfort or harm.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns appropriately.

The provider had systems in place to manage infection prevention and control (IPC); however, these were not consistently effective in practice.

When speaking to relatives, concerns were raised regarding the effective management of personal hygiene and environmental cleanliness. Relatives told us staff did not always ensure people’s hands were clean before eating. One relative said, “They [staff] might well wear gloves, but that doesn’t count for anything when they fail to notice that my relative’s hands are soiled”. Another relative told us, “They [staff] do wash their hands and wear gloves, but they don’t notice that my relative’s hands are dirty”. Inconsistencies in maintaining people’s personal hygiene and dignity put people at an increased risk of cross-contamination and infection.

Environmental concerns also presented infection risks. We identified stagnant water, decaying waste materials and unsafe external storage arrangements in the garden area. These hazards had not been identified through internal audits and increased the risk of infection and environmental contamination.

Professionals also reported inconsistencies in continence documentation and feed stock control processes. This reduced assurance that hygiene risks were consistently monitored and managed in line with people’s needs.

Although the provider had policies in place and staff had received IPC training, oversight and governance systems did not consistently identify or mitigate infection risks. As a result, people were not always fully protected from the risk of infection or cross-contamination.

The provider did not make sure that medicines and treatments were safe and met people’s needs. People were not consistently protected from the risks associated with unsafe medicines management.

The provider did not ensure the safe management of medicines. During the inspection we identified multiple medicines management failures. These included expired medicines stored in cupboards and medicines belonging to discharged people in storage. We found incomplete date-opened labels and incorrect storage of temperature-sensitive medicines. The medication trolleys were overstocked and there was inconsistent fridge temperature monitoring.

We found expired controlled drugs stored in medication cupboards, increasing the risk that people could be administered medicines that were no longer safe or effective. We identified a medicine that required refrigeration stored in a general medication trolley rather than in a medicines fridge, meaning the medicine was not kept in accordance with manufacturer’s instructions.

These failures increased the risk of people receiving medicines that were no longer safe or effective.

Medicines fridge temperatures exceeded the safe range of 2–8°C on multiple occasions, staff did not document any action taken in response. This meant the provider could not demonstrate that temperature-sensitive medicines remained viable.

We identified gaps in Medicines Administration Records (MARs). For 3 people, staff had not documented whether medicines had been administered or recorded a rationale for omission. Without documented rationale or follow-up, the provider could not demonstrate that people received their medicines as prescribed. This placed people at risk of deterioration, unmanaged pain, and avoidable harm.

Emergency medicines management was also unsafe. We found expired fast-acting glucose treatments in the emergency grab bag despite recorded checks. An oxygen mask in the resuscitation bag was also expired. Records showed inconsistent daily and weekly checks of emergency equipment. This placed people at risk of delayed or ineffective treatment during a medical emergency.

We observed interruptions during a medicine round and a medication trolley left unattended and unsecured. Interruptions during medicines administration and unsecured medicines storage increased the risk of administration errors, diversion, or unauthorised access to medicines. Relatives reported occasions where prescribed medicines were unavailable or delayed, leaders told us that medication errors were reported on an electronic system and that pharmacist support had improved. However, they could not demonstrate robust oversight or analysis of medication incidents to prevent recurrence.

Following feedback during the inspection, leaders took immediate steps to begin addressing these issues; however, the concerns identified demonstrated that systems had not been effective prior to the inspection.