About the service Holyrood House is a residential care home providing accommodation and personal care to 23 people at the time of the inspection. The service can support up to 29 older people, some of whom may be living with dementia related conditions.
People’s experience of using this service and what we found
People's health, safety and welfare was put at risk because the provider did not have effective systems in place to assess, monitor and improve the safety and quality of the service. There was a lack of provider and management oversight of the service.
At the last inspection, we found governance and monitoring systems had failed to identify areas of concern. This meant systems had failed to ensure risks to people were mitigated. At this inspection, there had been a significant deterioration in the quality of care provided to people. Serious concerns were found which had not been identified by the provider's quality assurance system. Management and staff had not effectively recognised and managed risks and incidents, therefore, people were placed at risk of harm.
Some risks to people, and the need to update care records, had been identified by the manager and provider before our inspection visit. However, action to mitigate risks to people's safety had not all been identified and addressed. The provider was open with us about the failings in the service and was committed to making improvements.
People had been put at risk due to the poor oversight of the safety of the building. At the start of the inspection, there was a serious risk with the safety of windows on the first floor. The provider addressed some of the issues and window safety had improved by the second day of the inspection.
At the last inspection, we found some risk assessments contained contradictory information meaning people were not kept as safe as reasonably practicable. At this inspection, we found risks were not always assessed appropriately. Staff received relevant training, but this needed to be extended to include guidance to assess risks to people. There was not an effective system in place to learn lessons from incidents or accidents. This meant people continued to be put at risk.
Safe infection control systems and processes were not always in place. Parts of the home were not clean. Systems for the management of people's medicines had not always ensured they were managed correctly.
Although people told us they felt safe, the systems in place failed to ensure people would always be protected from the risk of harm and abuse. Incidents of potential abuse had been overlooked. These concerns were not escalated to relevant partner agencies as required, such as the local authority. The Care Quality Commission (CQC) had also not been notified. Staff understood their safeguarding responsibilities, but we could not be confident that every incident was investigated.
People were not supported to have maximum choice and control of their lives and staff did not 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. People were not always given opportunities to make decisions about their care.
People did not always experience kind and compassionate care, as we found examples where people were exposed to the on-going risk of harm.
People did not receive responsive care, which met their needs. Care plans did not reflect people's current needs, and they were not an accurate or helpful tool for staff providing care. There was no evidence that people and their relatives had been actively encouraged to be involved in discussing or reviewing their own care on a regular basis.
We saw good interactions from staff and people and their relatives spoke positively about the care and support they received. People’s privacy and dignity was respected.
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 (published 18 February 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when they would improve.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection. We found significant concerns during this inspection resulting in an overall rating of inadequate.
Enforcement
We have identified five breaches in relation to safe care and treatment including risk management, infection control, premises and equipment, safeguarding people from abuse, consent to care and treatment, and how the service is managed.
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 for the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.