Atholl House

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to providing safe care and treatment to people. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 69 (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 have a proactive and positive culture of safety based on openness and honesty.

While leaders described expectations for concerns to be raised, we did not consistently see examples that safety events were investigated, reviewed, or used to drive learning and improvement. As a result, learning from safety events was not always embedded or used to support continual improvement across the service.

We saw some examples of quality assurance activity, including an audit schedule and spot checks, which identified issues and provided feedback to individual staff, with some follow‑up actions planned. However, we did not see that incidents, near misses or audit findings were consistently analysed to identify themes, record learning or drive preventative action. References to handovers did not demonstrate structured investigation or shared learning. This meant we could not be assured that safety events were used systematically to reduce the risk of similar incidents recurring across the service. Regarding learning from an incident, a relative told us, “I see no evidence that the lessons have been learned to ensure this doesn’t happen again.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had systems to support safe care and continuity, including personalised risk assessments, personal emergency evacuation plans (PEEPs), hospital passports, health action plans, and structured handovers. These helped staff understand people’s needs when circumstances changed. Staff using these care records recognised people’s strengths, communication needs and skills and helped promote confidence and independence during changes such as hospital admissions. This supported continuity of care and helped people experience safer transitions between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always demonstrate effective service‑level oversight to consistently improve people’s safety and wellbeing or ensure that safeguarding concerns were shared, reviewed, and learned from in a timely and appropriate way.

We saw evidence of safeguarding awareness and individual risk management, including daily management walkarounds to monitor safety and examples of proportionate, least‑restrictive safeguarding practice that protected people while promoting independence, particularly for people with learning disabilities.

The provider shared a detailed case study demonstrating positive risk‑taking, appropriate use of the Mental Capacity Act and partnership working with family and professionals to reduce safeguarding risks at an individual level. A relative told us, “They are not shy of making sure [my relative] is safe regarding urgent matters.”

However, we did not consistently see examples of safeguarding oversight at service level, including safeguarding logs, chronologies, partnership records or learning from safeguarding concerns, which limited assurance that concerns were always shared, reviewed, and used to strengthen safeguarding practice across the service.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

People were actively involved in discussions about their risks through personalised risk assessments and care planning, with accessible information and communication support used where required. We saw examples of positive risk‑taking, including a detailed case study demonstrating appropriate use of the Mental Capacity Act and proportionate safeguards that enabled a person with learning disabilities to make informed choices while reducing risk. This supported people to understand and manage their own risks, maintain independence and confidence, and continue to do the things that mattered to them without unnecessary restrictions.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We saw examples of regular environmental monitoring, including daily management walkarounds and spot checks, which identified and controlled risks such as trip hazards, fire safety, cleanliness, and infection prevention control measures. The provider checked and maintained equipment and facilities with hoists, slings, beds, and medicines storage in use and in date. The provider made reasonable adjustments such as safety guidance in preferred languages to support people with learning disabilities. This helped ensure people were supported in environments that were safe and well maintained, while enabling them to live as independently as possible within their own flats and communal areas.

The provider made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider planned and monitored staffing levels, with rotas in place and agency staff deployed where required to maintain continuity of care. Staff were supported by management oversight through daily walkarounds and spot checks. We saw training, induction and supervision processes in place, including competency expectations for medicines and person‑centred care. However, assurance around the consistency and quality of supervision records was still developing.

The provider ensured staff recruitment practices, including appropriate pre‑employment checks, were in place.

A relative told us, “Care visits are generally reliable.” Another said, “[The person] usually has at least one staff member who knows [the person] very well.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider monitored infection risks through audits and daily management walkarounds, supported by spot checks of cleanliness, hand hygiene and personal protective equipment use.

Spot checks and walkarounds showed staff followed infection prevention control procedures in practice, and equipment and communal areas were maintained in a clean and safe condition. This helped reduce the risk of infection spreading and supported people to receive care in environments that were clean, well-managed and safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider used established systems to support safe prescribing and administration of medicines. These included medicines administration records, regular audits, clear protocols for medicines used when required, and staff competency checks. We saw no examples of medicines being used inappropriately to control people, which helped ensure medicines were managed safely and in line with people’s needs and preferences.