CQC report explained · a nursing home
What the CQC found at Hunters Moor Neurorehabilitation Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Hunters Moor Neurorehabilitation Centre is rated Requires Improvement; care was responsive, but safety, dignity, consent and management checks needed further work.
The inspection was unannounced and took place on 2 and 8 August 2023. Four inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
People generally felt safe and received their medicines when needed. However, some medicine patches were not rotated correctly, thickener was not always stored securely, some areas were unclean, and care records did not always show what support had been given.
People received rehabilitation support tailored to their needs and had access to health professionals. But inspectors found mixed views about food, missed weight checks, limited consideration of people's freedom during 15-minute observations, and occasions where privacy and dignity were not respected.
The home was rated Good for Responsive and Requires Improvement for Safe, Effective, Caring and Well-led. The overall rating remained Requires Improvement. The home had not made enough progress since the previous inspection and remained in breach of Regulation 17.
Rehabilitation support
People received care and support shaped around their rehabilitation and wellbeing. Relatives also reported that people were making progress.
“People received responsive care and support tailored to their rehabilitation and wellbeing.” from the report
Access to health professionals
People could see a range of professionals at the home. Regular meetings helped staff keep people's needs under review.
“People had access to a range of on-site health professionals to support their rehabilitation, health and wellbeing.” from the report
Support during anxiety
Inspectors saw staff respond calmly when people became anxious and help them settle through activities and reassurance.
“We observed staff respond well to people as their anxieties heightened, diverting them to an activity and supporting them until they were calmer.” from the report
Complaints handled
People and relatives knew how to complain. Complaints that had been made were recorded and answered promptly.
“Where people or their relatives had made complaints, these had been recorded and responded to promptly by the registered manager, in line with the provider's policy.” from the report
Weak management checks
seriousThe home's audits did not reliably find problems with records, cleanliness, medicines and risk management. This was a continued breach of Regulation 17.
“The provider failed to operate effective systems and processes to maintain effective governance and oversight of the service.” from the report
Medicine patch records
seriousSome nicotine and pain relief patches were not applied to different body areas at the required intervals. A new body-map record was introduced during the inspection.
“Some medicines prescribed in patch form were not always administered in line with manufacturers' guidelines.” from the report
Consent and freedom
seriousMany people were placed on 15-minute observations without enough evidence that their capacity, privacy or freedom had been considered. Most of these observations were relaxed by the end of the inspection.
“We found the service was not always working within the principles of the MCA.” from the report
Food and nutrition records
needs fixingPeople gave mixed feedback about food, and cultural and dietary needs were not always met. Weight checks and food records were not consistently completed.
“Some people told us their cultural and dietary choices were not always followed.” from the report
Privacy and dignity
needs fixingSome people reported that staff communication felt disrespectful or that decisions were made without consulting them. Inspectors said more was needed to protect dignity consistently.
“A member of staff woke me at 05.30 and asked, 'Are you wet?', I found it really insulting.” from the report
- 01What checks now make sure nicotine and pain relief patches are rotated correctly and recorded on a body map?
- 02How are thickener, cleaning chemicals and other potentially harmful items stored securely?
- 03What has changed to improve kitchenette cleanliness and the condition of the environment?
- 04How do you assess consent and least-restrictive options before using 15-minute observations?
- 05How are food preferences, dietary and cultural needs, weights, and food intake now recorded and reviewed?
The inspection began as a focused review of Safe, Effective and Well-led, then widened to a comprehensive inspection after concerns about people's dignity and privacy; all five key questions were rated. This explanation was written from the published report of 29 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found unsafe medicines and risk management, weak oversight, and no registered manager at the time.
This was an unannounced focused inspection on 11 and 13 January 2022. Inspectors looked only at Safe and Well-led, following concerns about staffing, fluid intake, weight loss, call buzzers, observations and management support. They spoke with people, relatives, staff and professionals, and checked care, medicines, staffing and management records.
People and relatives said they felt safe and cared for. Staff understood safeguarding procedures, infection control was being followed, call buzzers were answered promptly, and people's fluid intake and weight were monitored. However, medicines were not always given as prescribed, known risks did not always have care plans, and required safety observations were missed.
The home received Requires Improvement for Safe and Well-led, changing from Good at the previous inspection. Inspectors found that quality checks had not identified important problems, incidents were not properly analysed, and staff training gaps were not addressed. The provider was told to produce action plans and received warning notices for two breaches.
People felt safe
People and relatives told inspectors they felt safe and had good relationships with staff.
“Relatives we spoke to told us they felt their loved ones were safe and happy in the home.” from the report
Safeguarding
Staff had safeguarding and whistleblowing training and understood how to use these procedures.
“The provider had clear safeguarding and whistleblowing systems in place which staff had received training and knew how to effectively use.” from the report
Infection control
Inspectors were assured that infection prevention measures, protective equipment and visiting arrangements followed the guidance checked during the inspection.
“We were assured that the provider was using PPE effectively and safely.” from the report
Prompt call-buzzer response
Inspectors found that staff responded promptly when people used their call buzzers.
“We found when people used their call buzzers to alert staff to their needs staff responded timely.” from the report
New leadership action
New therapy leads and a head of nursing had identified and acted on some improvements, including more detailed handovers.
“The provider had recently employed new therapy leads and a head of nursing who had identified and actioned a number of areas for improvement” from the report
Medicines were not always safe
seriousSome medicines were recorded as given when they had not been taken. This resulted in one person being admitted to hospital.
“We saw prescribed medication had been recorded as administered when it had not been consumed which resulted in a person being admitted to hospital.” from the report
Risks and observations were missed
seriousKnown risks did not always have detailed assessments or management plans. Required safety observations were not consistently completed.
“For example, one person required observations to be completed every 15 minutes and we found no observations had been completed for nine days in a 12-day period.” from the report
Building safety checks
seriousTemporary taped flooring repairs created possible trip hazards, and inspectors found no evidence of regular checks on some premises and equipment.
“We found maintenance was required to flooring in multiple places in the home where temporary repairs had been made with tape which were potential trip hazards.” from the report
Weak incident learning
needs fixingIncidents were not consistently recorded, analysed for patterns or used to improve staff practice.
“The provider failed to ensure incidents that occurred were sufficiently assessed for trends and patterns.” from the report
Training gaps
needs fixingThe provider knew that completion of fire safety, manual handling and nutrition training was low, but had not taken action to improve it.
“No action had been taken to improve the percentage of staff trained in these areas.” from the report
Limited management support
needs fixingThere was no registered manager at the inspection, and staff described poor communication, low morale and a lack of supervision or meetings.
“We don't get supervisions or meetings we haven't had them, there is no support and don't feel we are listened to.” from the report
- 01How do you now check that medicines are actually taken and recorded correctly?
- 02How are people's known risks assessed, and how do you make sure required observations are completed?
- 03Have the taped flooring repairs and the missing premises and equipment safety checks been completed?
- 04What action has been taken to improve fire safety, manual handling and nutrition training completion?
- 05Who is the registered manager now, and how can families give feedback or raise concerns?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection published in July 2019. This explanation was written from the published report of 22 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hunters Moor Neurorehabilitation Centre
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Hunters Moor Neurorehabilitation Centre →
- August 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Hunters Moor Neurorehabilitation Centre →
- July 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 6 May 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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