Background to this inspection
Updated
31 March 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
This inspection was carried out by three inspectors including a medicines inspector, a specialist advisor in nursing care 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.
Service and service type
All Hallows Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. All Hallows Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 5 people who live at the service and 11 relatives. We spoke with 11 staff members including housekeeping staff, care staff, nurses, the registered manager and the providers multi-site director. We reviewed 4 care records and a range of documents relating to the health and safety of the service, medicines administration and staff recruitment. We received feedback by email from 9 members of staff.
Updated
31 March 2023
About the service
All Hallows Nursing Home is a residential care home providing personal and nursing care for up to 50 people. The service provides support to older people. At the time of our inspection there were 29 people using the service. All Hallows Nursing Home provides care in one purpose-built building.
People’s experience of using this service and what we found
People were placed at risk of harm as the provider did not effectively manage the administration of prescribed medicines. The management of medicines had been identified as a risk by the provider and All Hallows Nursing Home was receiving support from both internal and external sources, but was failing to provide people with their medicines as prescribed.
The service had governance systems in place, but these were not always effective in ensuring the service was identifying and addressing short falls.
People and their relatives raised concerns about the lack of staff and the impact of using agency staff. The provider told us they have taken action to recruit more staff and use less agency staff.
People told us the food was of poor quality. Some relatives told us they took food in for their family member.
Most people chose to spend the majority of their time in their bedrooms which may lead to social isolation. Activities staff visited people in their rooms.
Care plans were being transferred to an electronic system. Some care plans did not fully reflect people’s needs, or the actions put in place to manage risks from receiving care and support.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People told us that staff were kind, caring and knew them well.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 15 February 2022).
Why we inspected
The inspection was prompted in part due to concerns received about medicines and care planning. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for All Hallows Nursing Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to the management of medicines and the provider’s procedures to monitor and improve the quality of care.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.