This inspection took place on 18, 19 and 23 January 2018 and was unannounced.

Atholl House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. This service provides nursing and personal care for up to 84 people. At the time of this inspection 60 people were living there, some of whom were living with dementia.

At the time of this inspection there was no registered manager. A manager had recently been appointed and we confirmed with them that they were in the process of applying to be registered with the Care Quality Commission. 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 manager was present throughout this inspection.

At the time of our last inspection undertaken on 22 and 23 September 2016 we rated the service as Requires Improvement. We found shortfalls related to staffing, risk management and quality assurance, However; no breaches of regulations were identified. At that time these topic areas were included under the key questions of safe, responsive and well-led. We reviewed and refined our assessment framework and published the new assessment framework commencing from 1 November 2017. Under the new framework these topic areas are included under the key questions of safe, effective, responsive and well-led. Therefore, for this inspection, we have inspected these key questions and also the previous key question to make sure all areas are inspected to validate the ratings.

At this inspection we saw improvements had not been made in the areas identified at our last inspection. In addition we identified a number of other concerns including breaches of regulation. These breaches include: safe care and treatment, dignity and respect, person centred care and governance.

This has resulted in the overall location being rated as requires improvement.

The provider had systems in place to monitor the quality of support given and to make changes when needed. However, these systems were ineffective and did not identify the concerns or improvements required that we found at this inspection.

The provider did not have effective infection prevention and control procedures in place. Maintenance and repair processes were ineffective and did not keep people safe from the environment within which they lived. During this inspection, pieces of equipment were removed from use as they were ineffective in keeping people safe. People’s medicines were not safely stored.

People’s rights were not always protected by those supporting them and the management team did not always follow the principles of the Mental Capacity Act when making decisions that effected people.

People were not always treated with dignity and their privacy and confidentiality was not respected or protected. Interactions with staff members were task focused and did not value the person as an individual. People did not have sufficient opportunity to engage in activities that they found interesting and stimulating.

Although people received care from staff that had the skills and knowledge to meet their needs they were not always treated in a kind, caring and considerate manner by those supporting them. Physical adaptations to parts of the property had not been made to enable people to safely move around their home. People did not receive information in a way they could access. The management team were unaware of the accessible information standards and had failed to implement these at Atholl House.

People received care from staff members who knew their individual likes and dis

Our inspection took place on 22 and 23 September 2016 and was unannounced. Atholl House is a care home which provides accommodation for nursing and personal care for up to 58 people. The location provided long term, short term, palliative and end of life care. At the time of our inspection the registered manager told us there were 51 people living at the location.

We last inspected the service on 29 January 2014 at that time the provider was meeting the requirements of the law we assessed them against.

People were not always supported by staff who understood their risks and how to manage them. People did not always receive care and support in a way that reflected the risk management plans in order to reduce risks. Staff were often very busy and people sometimes felt had to wait for support.

The registered manager had systems and processes in place to monitor and analyse the quality of the service, however we found the systems were not always effective in identifying issues. People and their relatives had limited opportunities to provide feedback and felt communication could be improved.

People were supported by a staff team who were able to recognise the signs of potential abuse and how to report it.

People received their medicines as prescribed and were given medicines by staff who were suitably trained. People’s medicines were stored safely.

People received care and support from staff who had been recruited safely and received suitable training and support.

People were supported to have sufficient to eat and drink. People were given a choice of what they ate and drank and specific dietary needs were catered for.

People were asked for their consent to care and support and the principles of the Mental Capacity Act 2005 were being applied. Assessments of people’s capacity were completed where people lacked capacity.

People were supported to access healthcare services when required and maintain their health.

People were supported by a staff team who treated them with kindness. People were supported to make decisions about how their care and support was provided and how they spent their leisure time. People were treated with dignity and respect and were encouraged to maintain their independence. People were supported to maintain relationships that were important to them.

People and their relatives were involved in the planning and review of care and were supported by staff who provided care and support in a way that respected people’s preferences. People were supported to engage in activities which they enjoyed and were encouraged to engage in personal interests and hobbies.

People and their relatives knew how to make a complaint and felt confident that complaints would be effectively managed. We looked at complaint records and saw complaints were logged and investigated and actions taken to improve practices had been documented.

People and their relatives knew who the registered manager was and staff felt supported by the registered manager. Staff felt concerns and suggestions were listened to and acted on and the registered manager had a good understanding of their responsibilities.

During our inspection we spoke with nine people, five visitors, four members of staff, two external professionals, the manager and the provider. We looked at four people’s care records.

We found that people were supported in making day to day decisions about the care they received. One person told us, "I am kept well informed”. People’s dignity was respected by staff.

The care people received was reflected in their care plans. Care was regularly reviewed to ensure it met people’s needs. However, we found that records relating to how one person’s skin was supported to be healthy was not properly completed

Staff used equipment correctly and followed guidance to limit the risk of the spread of infection.

We found that staff were recruited in a way which determined they were appropriate people to deliver care and checks were carried out to ensure their suitability. One person told us, “Staff are excellent”.

The service had a clear complaints procedure. We found that complaints were appropriately recorded and progressed.

We found that where people had capacity they were informed of their care and treatment options and consent was obtained before this was provided. Where people lacked capacity, a best interest meeting would take place to ensure their specific needs were met.

We looked at three care plans that provided sufficient information to support staff’s understanding about people’s assessed needs and how to care for them. “One person who used the service said, “They couldn’t look after me any better even if I was the queen.”

We found that appropriate systems were in place to ensure people were protected from potential abuse.

We looked at systems and practices for the management of people’s prescribed medicines and found them to be robust and ensured people were supported to take their medicines safely.

The staff training programme showed that staff were provided with relevant training to ensure they had the skills and competence to care for people.

The provider had an effective quality assurance monitoring system in place, to ensure people were protected from unsafe care and treatment. We spoke with a person who lived there who said, “I have lived in three other care homes and this is the best.”

We asked people who lived at the home about the management of their medicines and we found that people were happy with the service looking after their medicines and when their medicines were being administered.

We reviewed the service’s compliance with a number of essential standards in November 2011. We found that the service was non compliant with four and could have made improvements with one of the essential standards.

This review was carried out to look at all the information we had received since we told the provider where they needed to improve. We visited the service to check the improvements.

We spoke with people that used the service and a relative of a person that lived at Atholl House.

One person told us that that the care was “very good and they can’t do enough for you”.

People told us that staff were very friendly and that people living there were supported in the right way.

One relative told us that the care was “excellent, is the best home in Wolverhampton” and that the care was “first class, very good, relative well looked after”.

Care plans provided detailed information to support staff's understanding about how to care for people appropriately. People are involved in their care planning so the service they receive is specific to their needs.

One visiting relative said, “The care here is brilliant.”

One person who uses the service said, “The staff assist me to have a wash and get dress and they do this well.”

People who use the service cannot be entirely confident that all staff will have the skills to protect them from potential abuse.

One person who uses the service said, “The staff are polite and talk to me nicely.”

A visiting relative said the care was fantastic and staff always take the time to talk to them.

The management of prescribed medicines remain unsafe and this could compromise people's treatment.

Efforts had been made to improve systems in monitoring the quality of the service delivery. However, we identified a number of shortfalls that could have a negative impact on the care and support people receive.

One person said, “I’m happy with the service provided. “

Another person told us, “I’m happy living here.”

A person who uses the service told us, “The service is cheerfully provided.”

People made some positive comments about the care they receive. However, we found some shortcomings in how care is planned and provided which could place people at risk.

“The staff know me that well they don’t have to ask me how I need to be cared for.” “I thank the people who look after me.”

The care plans we looked at did not contain any evidence to show people's involvement in their care planning; we did not see people's comments or their signatures.

Three staff spoken with demonstrated a reasonable understanding of safeguarding people from potential abuse.

One person who uses the service said, “The staff are respectful and polite.”

Another person who lives there said, “The staff are very good.”

The staff training records we looked at showed that staff do not receive sufficient training to ensure they have the skills to provide an effective service.

We observed staff attending to people in a caring manner.

"When I buzz (nurse call alarm) they come quickly.”

Another person said, “There are always staff around when you need them.”

We found that the quality assurance systems in operation were ineffective to ensure people receive a good service.