This inspection took place on 19 July 2017 and was unannounced. At the last inspection on 11 and 27 October 2016, we asked the provider to take action to make improvements to safety, nutrition, care planning and the governance of the service. At this inspection we found that the action has been completed and substantial improvements had been made.

All Hallows Hospital is registered to provide care and support for up to 30 people. On the day of our inspection the service was supporting 18 people. The service provides residential care and nursing, respite and palliative care, including for people with a long term neurological condition.

The service is required to have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At this inspection the manager had recently been recruited and had submitted their application to register with the Care Quality Commission.

An assessment of people’s care and support needs was carried out by the service before people began using the service. This was to ensure that the service could meet the needs of the person before providing care and support. Risks to people from receiving care and support were assessed, as part of this process and actions put in place to mitigate any identified risk. Care plans clearly identified actions staff should take to ensure people were kept safe. Risk assessments were regularly reviewed and amended when required.

People received their medicines safely as prescribed. There were systems in place to ensure that the administration of medicines was recorded effectively. This included checking that staff complied with procedures. Where staff were identified as not administering medicines safely appropriate action was taken.

Care plans were written with the involvement of people and their relatives, where appropriate. People’s care and support needs were identified in care plans with clear instructions for staff as to how these were met. Care plans also recorded people’s social interests. The service provided support for people to maintain their social interests and develop others.

Since our last inspection the provider had reviewed how the service was managed. There had been a number of senior personnel changes and the provider had reviewed its approach to strategy and operations. This had resulted in a more effective governance framework and the provider developing a clearer direction for the service. People told us they had been involved and consulted with the changes. The chief executive of the provider told us that this process was on-going and further improvements were planned.

This inspection took place on 11 and 27 October 2016. The inspection of 11 October was announced and the second inspection took place within a stated timescale.

The service provides long term care for up to 16 people with complex nursing and care needs. It also provides rehabilitation services and end of life care.

The service has a condition of registration to have a manager registered to manage the service. The registered manager resigned after our first inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

All Hallows Hospital is a permanent home to some people with complex health needs. The culture of the service did not reflect this. Care was provided in respect of healthcare but did not always take account of the whole person. Staff were generally caring but systems and practices had not been developed to reflect the nature of the service provided.

Risk management and quality assurance processes were not implemented effectively to ensure people received safe care and treatment. The monitoring of medicines had failed to identify that nursing and care staff were not effectively recording when medicines had been given, meaning that we could not be sure that medicines had been given as prescribed. We were given an example when a person had not received the percutaneous endoscopic gastronomy feed (PEG) as required. Staff did not demonstrate an understanding of the importance of effective recording. Following our first inspection the service had taken steps to address this issue but recording was still not being carried out effectively on our second inspection. Risk assessments did not contain sufficient detail to enable staff to effectively manage risk and were not always reviewed regularly to ensure they met people’s changing needs.

People had mixed views as to whether there were sufficient staff available to meet their needs. We were given two different methods of how the provider was planning staffing levels. One method was based on capacity and the other on dependency. This did not assure us that the provider was ensuring there were adequate staff available to meet people’s needs.

People told us that the food was good and that they received a choice of what they wanted. However, we

We carried out this inspection in response to concerns that were raised with us anonymously. We were told that people were not cared for properly and that staff were not supported in their work.

We spoke with four people who used the service and one person’s relative. We observed how staff worked with people and spoke with four members of staff, the acting matron, the operational administrator and the interim chief executive.

There had recently been changes to the senior staff at the service after a period of uncertainty. The long term matron, who was also the registered manager, resigned in August 2013 and since then there had been a number of matrons appointed who had not remained in post. There were also disciplinary issues that resulted in staff leaving the service.

People told us that they received a good service. One person told us, “I have been cared for well.” Another person told us that staff, “… always help me if I need it.”

We saw that care and treatment was delivered in a way that was intended to ensure people's safety and welfare.

We found that staff had not been supported properly through supervision since the changes to management, but that since the appointment of the acting matron the staff we spoke with told us that they felt that things were improving. One staff member said, “It has been a difficult time, but things are getting better now.” All of the staff said that they received training essential for caring for the people they supported.

This inspection was conducted in respect of the home care service run by the provider, All Hallows Healthcare Trust.

During this inspection, we spoke with five people who used the service, five relatives of people who used the service, three staff members and the manager of the service.

The people we spoke with were happy with the care they received from the service. One person told us, “They are great, I couldn’t manage without them, they provide you with anything you need.” Another person said, “You just have to ask if you want any help and they will help.” A further person said, “I am very thankful for the service.” One relative told us, “The staff have gone beyond what we would expect.” A further relative told us, “I am jolly glad that they are there, nothing is too much trouble.”

We saw that people had received an assessment of their needs before they started using the service. The care was planned and delivered in line with their individual care record.

People told us that they felt safe when staff were providing care within their homes. We saw that the service had taken the appropriate steps to ensure that people who used the service were protected from the risk of abuse.

The required recruitments checks were being undertaken by the service before staff commenced their employment. The staff told us that they felt well supported and trained. We saw that a variety of training was available to the staff to ensure that they had the necessary skills and experience to provide care safely.

The service regularly assessed the quality of the care they provided and responded to any complaints or concerns that were made.

People who use the service told us that they were offered choices about aspects of daily living, including activities and food. One person told us "I was looked after very well. They were able to give me what I wanted for meals even if it wasn't on the menu."

Care plans were up to date and regularly reviewed to ensure that people were given the treatment and care they needed. Risk assessments were made on relevant areas to protect the safety and welfare of people. People told us that it was a clean and comfortable environment. "To be able to see the same friendly, cheerful faces on a regular basis was wonderful." Another person had written in a survey 'I am sure that your high standard of care certainly helped me recover so quickly.'

The service had been professionally audited for cleanliness and infection control procedures against the Department of Health code of practice, and been awarded a very high mark.

Staff training was comprehensive, with much of it done by in-house trainers. Staff were praised by people for their professionalism as well as their friendliness.

The provider used a comprehensive system of audits and monthly key performance indicators to ensure that standards were maintained. Regular surveys of people who used the service helped to identify areas for improvement, although most survey respondents were full of praise for the service.