Holyrood House

Holyrood House is a residential care home providing personal care to 25 people aged 65 and over at the time of the inspection. The service can support up to 29 people. Accommodation is provided in one adapted building, with bedrooms and communal facilities spread over two floors.

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

People did not always receive a safe and well led service. People were exposed to the risk of harm as the provider had not identified, assessed or mitigated risks. This included risks related to people's health and care needs, as well as environmental risks. Lessons had not been learnt where accidents had occurred.

Medicines management put people at risk of harm. We could not be assured people received their medicines as directed. People who received time specific medicines did not receive these in line with the prescriber's instructions. Stock checks were not always consistently completed.

The providers systems to monitor the quality and safety of the service were not effective in identifying improvement or driving quality at the service. The inspection identified shortfalls in relation to the management of medicines, staff training and risk mitigation. The providers systems had failed to identify and address these concerns.

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 Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 18 December 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the management of risk, and infection control. A decision was made for us to inspect and examine those risks. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. Following the inspection, the provider implemented additional documentation to support the safe management of medicines. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holyrood House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment, staff training and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good . We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

People had individualised covid care plans and isolation plans in place to ensure staff knew how to support people in the event people were required to isolate.

The provider has increased the domestic hours to enhance cleaning during the COVID-19 pandemic.

The service had a robust continuity plan for the event of a COVID-19 outbreak at the home.

Holyrood House is a residential care home providing personal care to 19 people aged 65 and over at the time of the inspection. The service can support up to 29 people.

Accommodation is provided in one adapted building, with bedrooms and communal facilities being spread over two floors. There is a lift to the first floor.

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

There was evidence of improvement around leadership, oversight and management within the service. This meant risks to people's health and safety was reduced, although additional work was needed to ensure the new practices were sustained.

Improvements had been made to infection control and prevention practices. Equipment and the environment were clean and there was sufficient cleaning taking place to keep people safe from the risk of infection. We gave the registered manager advice on where to find appropriate guidance to make further improvements.

Staff were recruited safely; further work was needed to ensure there was a clear audit trail in the staff files to show when recruitment checks had been obtained or followed up where needed.

The provider had made improvements to the environment to reduce the risk of harm to people.

Care plans and risk assessments were in place for people's support needs. These had improved in quality since our last inspection. However, further work was needed to ensure all care records were kept up to date and reviewed regularly. The registered manager had an action plan in place to address this.

Risks towards people’s health and safety were reduced. The assessment, monitoring and mitigation of risk towards people who used the service had improved.

Improvements had taken place to the management of medicines. Staff had positive links with healthcare professionals which promoted people’s wellbeing.

People, relatives and staff felt there were positive changes taking place and the registered manager was listening to their views and opinions.

People felt safe and well looked after. Relatives said they were confident that staff provided good care in a safe way.

Staff were patient, kind and respectful towards people. Care was person-centred and staff had time to chat with people during the day.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. Families confirmed that they were able to contribute their views on their relative’s care and support.

A registered manager had come into post since the last inspection. They were making positive changes to the service, and people, staff and relatives spoke highly of them.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 23 April 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since April 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check that the provider 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 and Well-led. No areas of concern were identified in the other key questions. We therefore did not inspect them.

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 coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holyrood House on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

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.

Holyrood House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates up to 29 people. At the time of our inspection 23 people were using the service.

There was 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.

The last comprehensive inspection took place in May 2017, when the service was rated Good.

At this inspection the home has been rated Requires Improvement. This is the first time the home has been rated Requires Improvement.

Risks to people were not always appropriately assessed, monitored and mitigated. This had the potential to put people at risk, and meant staff did not have the information to support and keep people safe. The quality assurance framework was not sufficiently robust and had not identified all the issues we found during the inspection. When actions had been identified, the quality assurance process had not always ensured that these were completed.

People were supported with food and nutrition but records relating to this had not always been consistently or effectively completed.

Care plans were in place but did not provide staff with guidance that was up to date to meet people's needs in a personalised way.

A complaints procedure was in place and displayed so that people would know who to talk to if they had a complaint. However, not all complaints were dealt with in line with the provider's policy.

Accidents and incidents had not been reported where required in line with company policy. This prevented the service implementing prevention methods to avoid reoccurrences.

The environment was clean and tidy, but two people's bedrooms had strong odours. The registered manager took action during the inspection to resolve this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People's needs and choices were assessed and mental capacity assessments were undertaken. People were supported to access health care services.

We saw some warm, friendly, caring interactions between staff and the people they were supporting. Staff made efforts to communicate with people in a way they could understand. Visitors were made to feel welcome.

People and their relatives were involved in the running of the service, through meetings and surveys.

People were positive about the registered manager. The registered manager was working reduced hours at the service and this had impacted on service delivery. The registered manager was aware of their responsibility to uphold legal requirements, including notifying the CQC of various matters.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. You can see what action we told the provider to take at the back of this report.

The service had a manager in post as required by a condition of registration with the Care Quality Commission (CQC). A registered manager is a person who has registered with CQC 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.

We last inspected the service in November 2014 and rated the service as ‘Good.’ At this inspection we found the service remained ‘Good’ and met all the fundamental standards we inspected against.

People we spoke with told us they felt safe living at Holyrood House. We observed warm and positive interactions between people, the staff and the registered manager, and people were relaxed and at ease in their home environment.

We found that people's individual needs were assessed and the registered provider had put risk assessments in place to manage and reduce the risk of avoidable harm. The registered manager was aware of their obligations in relation to managing and reporting any safeguarding concerns.

The staff we spoke with understood the risks to people's wellbeing and knew what action they must take to help minimise risks. Service contracts were in place to ensure equipment remained safe to use. The environment had undergone some refurbishment in the year prior to our inspection. The registered provider employed domestic staff but we found some areas of the home had not been maintained and cleaned effectively. These issues were addressed during and immediately after the inspection.

We found that the management and administration of medicines was safely carried out. Staffing levels on the day of our inspection were adequate to meet people's needs. Recruitment policies, procedures and practices were followed to ensure staff were suitable to care for and support people living at Holyrood House.

People told us staff were caring. People were involved in decisions about their care and we observed people being offered choices, such as what they wanted to eat and drink. People's privacy was respected.

We saw that people were supported according to their person-centred care plans, which reflected their needs well and which were regularly reviewed. We found that people were supported to access healthcare services.

People received suitable nutrition and hydration to maintain their levels of health and wellbeing. People told us they had enough to eat and drink, and enjoyed the food. We saw people had access to refreshments and snacks during the day. The mealtime we observed was relaxed and organised. Food was presented well and people were able to choose what they wanted to eat.

People were supported to eat in a supportive and calm setting that provided an opportunity to socialise as well as eat.

People had the opportunity to engage in various pastimes and activities if they wished to do so.

There was a complaints procedure in place and people were able to raise concerns.