18 April 2023
During an inspection looking at part of 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.