8 February 2023
During an inspection looking at part of the service
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.