Archived: All Hallows Care Home

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.

All Hallows is a residential care home providing the regulated activity of personal and nursing care. The service is provided from purpose built premises situated in Bungay on the Norfolk and Suffolk border. The service provides short-term and long- term care and support, including nursing care for up to 50 people, including those living with dementia. At the time of our inspection there were 17 people using the service.

People’s experience of using this service and what we found

The service had experienced a high turnover of staff and challenges recruiting both care staff and nurses. As a result, there was a high- level use of agency staff which people told us occasionally impacted on the quality of care they received. A number of incentives had been introduced to improve the ability to recruit and retain staff.

There were systems in place to monitor the quality and safety of the service. Infection prevention and control measures were in place. Risks to individual and environmental safety had been assessed. However, we found people were at risk of injury from unguarded radiators, presenting a risk of burns to people not identified in the provider’s risk management audits. In response to our findings immediate action was taken to rectify this.

Prior to our inspection we received concerns regarding the management and oversight of people’s medicines. Recent shortfalls identified in the management of medicines had been addressed with action plans in place to ensure improvement.

People had their needs assessed prior to receiving care and support. Staff worked with various social and health care professionals. Referrals for specialist advice were submitted in a timely manner.

People received care and treatment from staff who had the relevant knowledge to meet people's needs. There was a system to ensure all staff had training relevant to their roles and their competency assessed. Training courses and events were relevant to the health and support needs of the people living at the service.

People were supported to have maximum choice and control of their lives and staff provided them with care in the least restrictive way possible and acted in their best interests. The policies and systems in the service promoted this practice.

People told us the majority of staff were kind and caring, treated them with dignity and respect and maintained their privacy. Where we identified concerns with the conduct of one member of agency staff this was dealt with promptly by the registered manager to protect people from unsafe care.

Care records contained clear information covering all aspects of people's individualised care and support. Information about people was written in a respectful and personalised way.

There was a complaints process in place which was managed effectively. The provider had procedures in place to identify and address people's wishes and choices including the planning of their end-of-life care.

The service had a new manager in post who was being inducted with support from regional management teams. Systems and process had been utilised effectively to ensure improvement to the quality and safety of the service.

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 the service under the previous provider was Good, published on 17 May 2018.

Why we inspected

The inspection was prompted in part due to concerns received about the management of people’s medicines and oversight of the service. 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. This included checking the provider was meeting COVID-19 vaccination requirements.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The service was clean, hygienic and free of unpleasant odours.

All staff had received recent training in infection control and prevention.

Personal protective equipment (PPE) stations had been created throughout the service. There were plentiful supplies of PPE and staff were observed wearing this appropriately.

There was effective zoning and cohorting of staff in response to a COVID-19 outbreak. The environment had been adapted to support social distancing. Extra staff rooms had been created to support distancing between staff.

Regular checks were in place to ensure effective infection prevention and control practices were followed.

Individual risk assessments had been conducted in consultation with people who used the service.

Risks to staff were identified. Any vulnerabilities in relation to COVID-19 were identified with actions implemented. This included risks of acquiring COVID-19 infection for staff from Black, Asian and Minority Ethnic backgrounds (BAME).

The service had appropriate infection control policies and procedures in place. These were developed in line with current government guidance.

Further information is in the detailed findings below.