Atholl House Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines management and staffing.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always ensure there was a proactive and positive learning culture. When incidents or accidents had occurred, these were recorded however they were not always investigated or reviewed to identify any learning. The incident forms did not always reflect the action that had been taken. There was no overall analysis of the incidents which occurred so that trends could be considered. Both the Local Authority and the Integrated Care Board (ICB) had recently completed site visits of the home and had given the provider action plans. Despite these action plans being in place we found timely action had not always been taken to address concerns. For example, the Local Authority had identified in December 2024 suitable window restrictors were not always in place, we found this had not been acted upon during our site visit. However, the registered manager was able to give us other examples where learning had been applied. They told us about safeguarding and complaints that had been made, the action they had taken, including the improvements they had made to their practices and the how they had shared this learning with the staff team.

The provider did not always ensure, establish and maintain safe systems of care. There was a pre assessment process in place which ensured people’s needs could be met before they moved into the home. However, improvements were needed to ensure these captured people’s preferences and that information from these were used to develop care plans and risk assessments. For example, 1 person had been identified at high risk of falls, although their mobility needs had changed, there was no reference to this risk in the persons care file.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We received mixed feedback from people around the care culture of the staff. We could not be assured people would always feel confident to share concerns or ask for support from staff if they needed this. Several people told us they did not like asking staff for support and waited until they were asked. One person when asked about their call bell told us, “I can press it but then, especially at night the staff aren't happy with me”. They went onto explain, “They are full of attitude, you have to just like it or lump it.” Other people told us they were happy with the staff that supported them and would ask for support when needed. One person said, “The staff are very helpful, if you have a problem you can talk to them. They are very approachable”. However, there were procedures in place to identify and raise safeguarding concerns. We saw when concerns had been shared or identified these procedures were followed so appropriate action could be taken. Staff told us they had received safeguarding training and were able to explain the process to us. When needed Deprivation of Liberty Safeguards (DoLS) were in place for people.

The provider did not always work well with people to understand and manage risks. Care plans were not always consistent, clear or followed by staff. Some of the care plans we viewed lacked detail including people’s preferences, and the levels of support they may need. For example, 1 person’s mobility care plan referred to them being ‘bedbound’ and ‘able to transfer to a wheelchair’. The person had remained in bed since their admission and when asked, staff were unable to confirm if this person was able to transfer. Other people’s care plans were not always followed for example, when people required changes of position from pressure relief or recommended amounts of fluids. Records did not reflect this care had been provided in line with these plans. Another person was not using an aid that helped their posture, whereas another did not have a protective bumper on their bed as documented in their care plan. No one had come to harm because of these concerns. We received mixed feedback from people and relatives on how their risks were managed. One person said, “They hoist me out of bed. Sometimes there’s 2 staff but mainly there’s 1”. Another person told us, “I feel very safe here”. A relative told us, their relation always had the buzzer so if they needed assistance, they could call for support. However, other care plans were in place and were detailed including when people had specific health needs, management of diabetes and when they required specialist diets.

The provider did not always detect and control potential risks in the care environment. We saw areas of the home which were unsafe. This included; hoists being stored in communal corridors, which could pose as a trip hazard and suitable window restrictors were not always fitted where required. The health and safety audit that had been completed had not identified these risks. After our site visit, we received confirmation that our concerns had been addressed. People and staff raised no concerns around the safety of the environment.

The provider did not always make sure there were enough staff available to support people. Although staff felt there were enough of them, we could not be assured people always received support when they needed it. We saw people had to wait for drinks or care as staff were supporting other people, in other areas. One person waited over 30 minutes for support. The records we viewed confirmed people did not always receive support as needed. For example, when they needed changes of position for pressure relief. One staff member told us they had not had time to read a person’s care plans, which showed the levels of support they needed. The dependency tool the provider had in place to work out the number of staff that was needed in the home was ineffective. This had not been completed since January 2024 and therefore did not accurately reflect the needs of people living in the home. We received mixed feedback on staffing in the home. One person told us, “I get up about 6.30. I dress myself. I don’t get brought a cup of tea until about 8, they are too busy”. Another person said, “I do wonder sometimes if there is enough staff, they are always so busy, but they do answer my buzzer quickly”. Another commented, “I won’t fault them but I won’t ask for help as they are so busy, I don’t like bothering them. For me there’s enough staff I can’t speak for others.” However, staff told us and records confirmed staff had received training. This included mandatory training and training that was specific to people’s individual needs. We reviewed the training matrix, and this confirmed staffs training was mostly up to date. Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

The provider did not always assess or manage the risk of infection. The Integrated Care Board (ICB) had completed a visit where they had identified areas of improvement, there was an action plan in place, and the registered manager was working towards completing these actions. This included implementing an internal infection control audit which they had recently introduced. People and relatives raised no concerns with infection control. One person said, “My room is immaculate, have a look at my bathroom, they clean it every day”. Staff confirmed to us they had received training and had enough Personal Protective Equipment (PPE) available to them.

Medicines were not always managed in safe way. We viewed medicines administration records for people. We saw 1 person had not received a medicine they were prescribed as it was out of stock. It was unclear why this medicine had run out and adequate action had not been taken to ensure this medicine was made available. Another person was prescribed medication ‘as required’ for agitation. There was no ‘as required’ guidance in place for this. The records showed this person was receiving this frequently. Records we viewed did not show this person was always agitated when this was administered. This meant we could not be assured this person received this medicine at the right times. During our site visit the registered manager took action to ensure these concerns were addressed. We also found stock checks of medicines were inaccurate. The processes that were in place to monitor medicines had not identified this or other concerns. The registered manager told us they would review the stock levels of medicines in the home. However, people were happy with how they received their medicines and raised no concerns. One person said, “They give me my medicines every day. I have more painkillers now than I used to have as I’m in more pain”. We saw other people received medicines as prescribed and ‘as required’ protocols were in place.