Atholl House

Date of Assessment: 12 March to 01 May 2026. Atholl House is an extra‑care housing scheme providing regulated personal care for older adults and adults with disabilities. People live in their own self‑contained flats and receive planned support to maintain independence, safety, and wellbeing while remaining part of the local community.

We assessed the service against the Right support, right care, right culture guidance. While many elements of right support and right care were evident in practice, right culture was not yet consistently embedded, limiting assurance that good care and positive outcomes would be reliably experienced by all people using the service.

People received kind, respectful and person‑centred care from staff who knew them well and understood their needs, preferences, and vulnerabilities. People were positive about staff support, responsiveness and activities, and there was evidence that people’s views influenced aspects of daily life within the service. Relatives consistently praised the commitment, compassion, and professionalism of front‑line staff, particularly when people had multiple needs or required reassurance during care.

Care was safe, and staff understood how to manage risks, respond to urgent health needs, and escalate appropriately. The environment was appropriate for people’s needs, and systems were in place to support medicines management, infection control, and safe working practices. Staffing levels generally enabled care delivery, although staff were sometimes under pressure and continuity could be affected at peak times.

The service demonstrated good person‑centred practice in assessing needs, involving people in decisions where possible, and adapting communication using accessible formats. Consent and Mental Capacity Act (MCA) processes were applied appropriately, and people’s rights were respected. Individual examples showed that positive outcomes were achievable, including increased independence, improved wellbeing, enhanced communication, and stronger community engagement.

However, while good care was delivered on an individual basis, the service did not consistently monitor or evaluate outcomes across the whole service in a way that drove continuous improvement.

Learning from complaints, incidents and feedback was not consistently embedded or applied across the service, resulting in recurring themes and a lack of sustained improvement.

Leadership and governance arrangements had improved since the last inspection, and systems such as audits, meetings, reports, and improvement plans were in place. Leaders recognised areas for development and were taking action to address them. As a result, the service was no longer in breach of regulations at this inspection.

Governance systems were not consistently embedded, resulting in variable communication and reliance on individual or family advocacy rather than robust systems.

Partnership working occurred but was not always seamless, and coordination between services was sometimes delayed or unclear. People and relatives could raise concerns, and front‑line staff were approachable, however, relatives described mixed confidence that escalation would consistently lead to timely action and learning.

Date of Assessment: 18 February to 26 March 2025. The service is an extra care service, people have their own tenancy in their own apartments with a separate registered agency providing the care visits who are based in the building. Not everyone who lived at Atholl house was in receipt of personal care, so we did not look at the support these people received. For people who received assistance with personal care, washing and dressing, meals, medication, social support, the staff supported older people and younger adults. This included some individuals who had a learning disability and autism. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

We found 3 breaches of the legal regulations in relation to the effective governance of the service, keeping people safe, and providing a person centred care experience to all people who received assistance with personal care. No one had come to harm as a result of these issues but there was a potential risk some people might. There were shortfalls in risk management and some potential high risks to people were not being assessed, explored, and planned for. Risk management systems did not always support managers and staff in the management of the risks people could experience. When accidents happened, these were not always investigated to consider if lessons could be learnt, we found some issues with how staff responded when some people had falls. People’s safety was not always promoted when they had assistance with their medicines.

People told us they had no concerns with staffing numbers, they saw regular staff at times they were happy with. However, managers did not have a system to tell them if they had enough staff and if they were deployed correctly. Managers did not have an effective system to check if people had received their care visits at the agreed times and durations.

People received support from health professionals, but the provider had not established a system for staff to record their actions, and for managers to check what actions had been taken. There was a new manager, staff now felt supported as they were available daily for advice and to direct staff, previously this leadership was not present. Staff received training but this was not specific to all the people staff supported. Training for staff about people’s needs who had a learning disability and who are autistic had not been effective; staff could not recall this training.

There were shortfalls with people experiencing a person-centred care experience who had a learning disability. Managers, and the provider had not produced personalised care plans to assist these people’s delivery of care. There were concerns about some aspects of the care these people received, that potentially it was institutionalised care and outdated.

The issues found during this assessment were a result of limited effective governance of the service by the provider. The provider had not established systems in line with what is required of them and did not ensure the care provided was audited and checked against these requirements. The provider and the new manager welcomed our feedback and said they would take actions to make improvements.

We have asked the provider for an action plan in response to the concerns found at this assessment.