Archived: All Hallows Neuro Rehabilitation Centre

All Hallows Neuro Rehabilitation Unit is a care home providing personal care to 5 people with an acquired brain injury at the time of inspection. The service can support up to 29 people.

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

At the last inspection improvements were required to ensure care was person centred, the principles of the Mental Capacity Act were followed, and that the management of the service was effective in identifying and acting upon areas for improvement. At this inspection we found that all required improvements had been made.

People received person centred care and were supported to participate in the planning of their care according to their needs. People’s wishes were sought and respected, and people were supported to make decisions according to their ability.

There was a comprehensive quality assurance system in place which was capable of identifying areas for improvement. We saw that areas for improvement identified by the system had been acted upon.

Medicines were stored safely within the home and administered in line with the instructions of the prescriber.

There were sufficient numbers of staff to meet people’s needs in a timely manner. Staff were recruited safely.

The service was clean and there were appropriate procedures in place to minimise the risk of the transmission of infection..

Mental Capacity Act all reports where covered in the scope of the inspection –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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was ‘requires improvement’ (29 July 2022). At that inspection the service was found to be in breach of Regulation 9: Person Centred Care, Regulation 11: Consent to Care and Treatment, Regulation 12: Safe Care and Treatment and Regulation 17: Good Governance. At this inspection we found improvements had been made in all areas and the service was no longer in breach of any regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 29 July 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, effective, responsive and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

Follow up

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

All Hallows Neuro Rehabilitation Centre is a 29 bed care home with nursing providing accommodation and personal care and support to people with complex healthcare needs associated with a neurological conditions, including acquired brain injury.

The premises is a single storey accommodation care home with four self-contained apartments. At the time of our inspection there were 13 people using the service including one person who was living in one of the self-contained apartments as part of their pre-discharge plan.

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

The culture in the home was not person centred. Emphasis had been placed on meeting people’s medical needs and associated risks. People were not fully supported to have choice and control and their preferences met regarding their care and support.

The Mental Capacity Act was not fully understood. We found shortfalls in related records and practice, which did not support shared decision making. People were not always supported to have maximum choice and control of their lives. Staff did not consistently support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Robust reporting and auditing systems were not in place to support effective oversight and governance and continuous learning in the home.

The registered manager and provider’s operations director were open and honest about the shortfalls at the service. They engaged with the inspection positively and were committed to making any necessary improvements.

People told us they felt safe and staff were kind and caring towards them. Staff were attentive in their approach and adapted their communication to meet people’s needs. Visitors could freely visit the service and were welcomed.

Staff understood the safeguarding practices and procedures within the home and protected people from avoidable harm.

Staff were familiar with people’s assessed medical needs and associated risks. These were assessed, monitored and managed safely.

Staff were recruited safely. There was mixed feedback about staffing levels and the use of agency staff. On the day of our visit there were sufficient staff to meet people’s needs.

Overall, safe management of medicines were in place and the home was clean with staff seen following recommended best practice for infection prevention and control procedures.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us on 08 July 2020 and this is the first inspection.

Why we inspected

The inspection was prompted by a review of the information we held about the service.

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.

Please see the effective, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and take further action if needed.

We have identified breaches in relation to need for consent, person centred care and good governance.

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 care and meet with them to discuss progress. We will work alongside the provider and local authority to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• Arrangements were in place for family and friends to access the service safely for visits. These included temperature checks and access to personal protective equipment (PPE).

• People were admitted to the service safely with the service following current government guidelines..

• Staff had access to the correct PPE at the service and were following government guidelines.

• Staff, people using the service and visitors had access to COVID-19 testing which was being carried out as per government guidance.