Archived: All Hallows Nursing Home

Updated 18 May 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This unannounced comprehensive inspection took place on 9 April 2018 and was undertaken by one inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed all other information sent to us from other stakeholders for example the local authority and members of the public. Prior to our inspection we contacted local authority for feedback about the service. We reviewed information we had received about the service such as notifications. This is information about important events which the provider is required to send us by law.

We spoke with 10 people who used the service and seven relatives. We observed the interaction between people who used the service and the staff throughout our inspection.

We looked at records in relation to five people’s care. We spoke with the registered manager and seven members of staff, including the human resources manager, nursing, care, activities and catering staff. We also spoke with a visiting health professional. We looked at records relating to the management of the service, training, and systems for monitoring the quality of the service. We also looked at three volunteer recruitment files, we had completed an inspection on another of the provider's services in March 2018 and visited the human resource office where we reviewed their recruitment processes.

Updated 18 May 2018

All Hallows Nursing Home Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. This service provides nursing care. All Hallows Nursing Home accommodates up to 50 adults, the majority being older people, in one adapted building.

There were 34 people living in the service when we inspected on 9 April 2018. This was an unannounced comprehensive inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last comprehensive inspection of 27 October 2016 this service was rated requires improvement. The key questions for safe, effective, responsive and well-led were rated as requires improvement and caring rated as good. There were breaches of Regulation relating to care planning and governance. At this inspection, improvements had been made and the service was now rated good.

You can read the reports from our last inspections, by selecting the 'all reports' link for All Hallows Nursing Home on our website at www.cqc.org.uk.

There were systems in place to provide people with a safe service. Staff were trained and understood how to safeguard people from abuse. Risks to people were managed well and staff were provided with guidance about how to mitigate risks. There were systems in place to provide adequate staffing levels to people who used the service. Staff recruitment processes were robust. Medicines were managed safely. There were infection control processes in place which reduced the risks of cross contamination in the service. Where incidents had occurred, the service had systems in place to learn from these and use the learning to drive improvement in the service.

Staff were trained and supported to meet people’s needs effectively. People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment. Staff worked with other professionals involved in people’s care to provide people with an effective and consistent service. People’s nutritional needs were assessed and met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The environment was appropriate for people using the service.

People were treated with care and compassion by the staff. People’s privacy and independence was promoted and respected. People were listened to and their views about how they wished to be cared for were respected.

People’s care was assessed, planned for and met. Care records guided staff in how people’s preferences and needs were met. Social activities were in the process of being improved. People’s choices were documented about how they wanted to be cared for at the end of their life. Compliments received by the service demonstrated that caring and compassionate care was delivered at the end of people’s lives. There was a complaints procedure in place and people’s complaints were addressed and used to improve the service.

The service had systems in place to monitor and improve the service provided to people. There were ongoing improvements being made in the Trust intended to further improve the service provided to people.