Archived: All Hallows Hospital

Updated 22 August 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 was a comprehensive inspection which took place on 19 July 2017 and was unannounced. The inspection team consisted of two inspectors 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. Our expert-by-experience had experience of supporting people using care services.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also looked at all the information we held about the service. This included monthly reports sent to us by the service as part of their conditions of registration and other information about events happening within the service and which the provider or registered manager must tell us about by law. We also looked at information we held about the service including previous inspection reports.

During our inspection we spoke with two people using the service, three relatives and observed how staff supported and interacted with people. We also spoke with two nursing assistants, one registered nurse, the housekeeping manager, the activities co-ordinator, the clinical educator, the deputy manager, the manager who the service referred to as matron, and the chief executive.

To help us assess how people's care and support needs were being met we reviewed three people's care records. We also looked at other records regarding the management of the service, for example medicines audits. We looked at the systems for assessing and monitoring the quality of the service.

Updated 22 August 2017

This inspection took place on 19 July 2017 and was unannounced. At the last inspection on 11 and 27 October 2016, we asked the provider to take action to make improvements to safety, nutrition, care planning and the governance of the service. At this inspection we found that the action has been completed and substantial improvements had been made.

All Hallows Hospital is registered to provide care and support for up to 30 people. On the day of our inspection the service was supporting 18 people. The service provides residential care and nursing, respite and palliative care, including for people with a long term neurological condition.

The service is required to have 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 this inspection the manager had recently been recruited and had submitted their application to register with the Care Quality Commission.

An assessment of people’s care and support needs was carried out by the service before people began using the service. This was to ensure that the service could meet the needs of the person before providing care and support. Risks to people from receiving care and support were assessed, as part of this process and actions put in place to mitigate any identified risk. Care plans clearly identified actions staff should take to ensure people were kept safe. Risk assessments were regularly reviewed and amended when required.

People received their medicines safely as prescribed. There were systems in place to ensure that the administration of medicines was recorded effectively. This included checking that staff complied with procedures. Where staff were identified as not administering medicines safely appropriate action was taken.

Care plans were written with the involvement of people and their relatives, where appropriate. People’s care and support needs were identified in care plans with clear instructions for staff as to how these were met. Care plans also recorded people’s social interests. The service provided support for people to maintain their social interests and develop others.

Since our last inspection the provider had reviewed how the service was managed. There had been a number of senior personnel changes and the provider had reviewed its approach to strategy and operations. This had resulted in a more effective governance framework and the provider developing a clearer direction for the service. People told us they had been involved and consulted with the changes. The chief executive of the provider told us that this process was on-going and further improvements were planned.