Hutton Manor Care Home

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 demonstrated a proactive and positive culture of safety characterised by openness, transparency and honesty. Staff listened to concerns regarding safety and ensured that safety-related events were reported, investigated and reviewed appropriately. Learning from incidents was used effectively to identify improvements and embed good practice across the service.

We found the management team to be open, transparent and committed to driving continuous improvement. Accidents, incidents and falls were consistently and accurately recorded. These were reviewed promptly, with clear analysis of trends and themes. Appropriate actions were taken in a timely manner following each event.

During our visit, staff told us they felt able to raise concerns; however, we received mixed responses regarding who they would approach. One member of staff reported, “I would worry about how confidential my concerns raised would be.” Other staff members told us they would report any safeguarding concerns immediately but would be more cautious about raising other issues, depending on who they needed to speak with.

We raised this with the management team, who responded promptly by developing an action plan and completing a risk assessment relating to staff relationships and confidentiality within the home.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, ensuring risks were effectively managed and monitored. Processes were in place to promote continuity of care, including during transitions between different services.

Safe systems and procedures supported individuals during admissions, changes in need and transfers to other services. Pre-admission assessments were carried out to confirm the service could safely meet each person’s needs. Staff gathered relevant information from individuals, families and external professionals, helping to ensure transitions were smooth and well-coordinated. Clear pathways within the service enabled staff to respond promptly and appropriately when people’s needs changed.

The provider collaborated effectively with healthcare partners, including GPs, community nursing teams and hospital services, to support timely referrals and safe information sharing. When people moved between services, essential details such as medication requirements, identified risks and communication needs were shared promptly and appropriately.

External professionals gave positive feedback about the provider’s approach to assessments and information sharing. One professional reported observing a thorough, person-centred assessment for an individual with complex needs prior to admission. Another professional stated they had no concerns about the provider’s communication or practice.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best ways to achieve this. Staff focused on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People told us they felt safe. One person said, “I am safe, they are kind people,” while another commented, “Oh yes, I am as right as a bobbin.” Another person stated, “Yes, I feel safe, there is always someone around, night and day.”

People can only be deprived of their liberty to receive care and treatment with the appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which forms part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Records demonstrated that people were cared for in the least restrictive way, in line with and promoting the principles of the Mental Capacity Act (MCA) 2005. Deprivation of Liberty Safeguards (DoLS) authorisations were sought when required and any conditions imposed were followed.

The provider worked with people to understand and manage risks by taking a holistic approach. Staff delivered care that met people’s needs in a safe and supportive way, enabling them to continue doing the things that mattered to them. Care records and risk management plans were reviewed regularly and updated when required.

Care records informed staff about risks associated with people’s health and wellbeing, as well as the actions required to mitigate these risks. For example, one person’s care records showed they had experienced multiple falls. The home took appropriate steps to reduce this risk, including referring the person to the falls team and using sensor mats. During our assessment, we observed the sensor mats alerting staff, who responded promptly to help prevent further falls.

People and their relatives told us they felt risks in the home were managed safely. One relative said, “Yes, I am looked after very well, it’s my home.” Another person told us, “I like to be independent, I do not often need help. If I ask for help, they are here before I have turned around.” Staff we spoke with were aware of people’s risks and clearly described the actions they would take if a person experienced a fall.

The provider detected and controlled potential risks in the care environment. They ensured that equipment, facilities and technology supported the delivery of safe care. People’s bedrooms were personalised with photographs and belongings. One person told us, “I chose my own paint as I wanted my room a different colour, and they did this for me.” A relative said, “We are slowly bringing in [name of person]’s things. It’s nice as you can go into the lounge and have a coffee.”

Equipment used to support people was suitable, well maintained and stored securely. Maintenance and safety checks were in place, including electrical checks, gas safety checks and equipment checks. People had Personal Emergency Evacuation Plans (PEEPs) recorded in their care files.

The provider ensured there were enough qualified, skilled and experienced staff, who received effective support, supervision and opportunities for development. Staff worked well together to provide safe care that met people’s individual needs. Recruitment processes were robust, including checks of employment history, character references, right to work and Disclosure and Barring Service (DBS) checks.

There were mixed views about whether staffing levels were sufficient. One person told us, “I have never come into the corridor and there is no one around.” Another person said, “Yes, I am alright, they look after me.” However, one person commented, “No, I don’t think they have enough staff, it’s worse at night.” A staff member told us, “I am happy with the staffing levels. Everyone mucks in together. I have set shifts. When there is sickness staff usually pick shifts up. We do not use agency.” Another staff member said, “We feel very rushed off our feet. There have been several times that I miss breaks because of that. There does not seem to be anyone taking the lead regarding break times which is a problem.” Another staff member told us, “Rotas are also a problem for us. We don’t know what we are doing from one week to the other.”

We reviewed the rotas, which showed appropriate staffing levels in the home. During the assessment, we observed staff present in communal areas as well as supporting people in their rooms. Staff told us overall they felt they received enough training to support them in their roles, and there was a training matrix in place showing completed courses. Staff supervisions had taken place; however, we identified some gaps, which were brought to the manager’s attention during the inspection for follow-up.

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

The home was visibly clean, tidy and free from unpleasant odours. During our assessment, we observed domestic staff carrying out cleaning duties throughout the day, following clear schedules that covered communal areas, high-touch surfaces and people’s private rooms. Cleaning records showed regular checks were completed and signed off by staff, demonstrating good oversight of hygiene practices.

People commented positively about the cleanliness of the home. One person told us, “They come in and clean, bring fresh towels.” Another said, “It’s definitely clean.” A third person shared, “They come in and clean and bring in fresh towels; it’s very good.” Bedrooms were maintained to a high standard, and staff respected people’s personal spaces while ensuring appropriate hygiene levels were upheld.

Staff had access to appropriate Personal Protective Equipment (PPE), which was stored correctly and used in line with current guidance.

Infection control audits were completed regularly and were comprehensive. These covered areas such as cleaning standards, laundry processes, equipment cleanliness. Where shortfalls were identified, action plans were completed and reviewed to ensure improvements were sustained.

Environmental measures were also in place to minimise infection risk. Equipment was visibly clean, well maintained and stored safely. Waste was segregated correctly, and laundry processes followed infection control guidance, with clear pathways for soiled and clean items to prevent cross-contamination.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored securely and managed by staff who had been trained and had their competency assessed.

People’s medication records (MARs) and care plans listed how individuals liked to take their medicines and listed medicines that they were allergic to; however, we found for one resident that allergy information was not recorded accurately on the MAR chart. No harm was caused to the person. Care plans included person‑centred detail, for example, we saw comprehensive information for a resident with Parkinson’s disease.

External medicines (such as creams and patches) were stored safely. Previous medicine cycle records did not always reflect that they had been applied as prescribed, however the home had recently made improvements to the process and records since the change were in place and accurate. Body maps were available to support staff to apply external medicines safely. The fire risk associated with emollient creams had been assessed and recorded. However, for one resident using flammable creams, their care plan noted the need for an individualised plan when using oxygen therapy, but no such plan was in place. This was in place by the end of the inspection.

Time critical medicines such as those to treat Parkinson’s disease were not always administered at prescribed times. Staff did not always document the time of administration of these medicines so we could not be assured that people always received these medicines as prescribed. A staff meeting in September 2025 showed that this had been discussed and staff had been made aware of the need to record times however we saw this wasn’t always done.

Protocols to give staff instructions on how to administer medicines given when required (PRN) did not always contain enough information for staff, for example for one person prescribed 2 laxatives there was no instruction for staff on which medicine was to be used first. We found for some people who had been prescribed laxatives, staff did not always complete records of their bowel monitoring as described in their care plan.

For powder used to thicken drinks to avoid choking and aspiration staff did not always record accurately when the powder had been added to drinks.

Audits were being completed monthly by the service and some issues relating to medicines had been picked up on and we saw evidence of actions being taken in response. However, audits had not always picked up on some of the recording issues we found during the inspection such as the amount of thickener to be used by one person and allergy information for another person. There had been no impact on people at the service and the provider took immediate steps to address this during the inspection and provided additional evidence to confirm actions taken.