Archived: All Hallows Neuro Rehabilitation Centre

Updated 16 May 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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 1 inspector, a specialist advisor in brain injuries and an Expert by Experience. An Expert by Experience made telephone calls to relatives to ask about their experience of the service. 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 Neuro Rehabilitation Unit 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 2 relatives. We spoke with nine staff members including the regional manager, service manager and care/clinical staff. We reviewed four care records and two recruitment files. Multiple records relating to the quality, safety and monitoring of the service were reviewed.

Updated 16 May 2023

About the service

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.