Archived: Hamilton House

People’s experience of using this service: People and their families told us they received good care and support, and were complimentary of the environment, staff and leadership of the service.

Overall, staff treated people with dignity, kindness and respect. However, we found some staff did not display such values, and there was, at times an institutionalised and task orientated culture, rather than a person-centred culture.

There were enough staff to meet people’s physical needs. However, people’s social needs were not always met. There were aspects of the providers recruitment processes which meant staff were not fully recruited safely.

Some staff told us they did not feel they had the skills and knowledge to provide care and support to people living with dementia and/or complex mental health. Whilst some staff received training in moving people safely, staff did not always put their training into practice. The provider’s training records showed significant gaps in staff training relating to mental health, dementia care, and behaviour that could challenge. Some staff also told us they did not feel adequately skilled to meet people’s individual needs.

Staff and the registered manager continued to have a limited understanding of the Mental Capacity Act 2005, which meant people’s human rights were not always protected. Deprivation of liberty safeguards (DoLS) applications were not always being followed.

There were variable opportunities for social stimulation, and on the first day of our inspection people sat around the edges of the lounge with nothing to do. Those living with dementia were not always supported by best practice principles relating to dementia care.

People’s risks associated with their health, social care and the environment had not always been assessed to help keep them safe. We reported one environmental concern to the local fire service.

The provider had limited oversight of the ongoing quality and safety of the service, and whilst there were some systems and processes in place to help monitor the service, these continued to not be effective.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014; we also made recommendations relating to staffing, the Accessible Information Standard (AIS), best practice principles relating to dementia care and for the provider to use the National Institute for Clinical Excellence (NICE) guidance.

More information is in Detailed Findings below.

Rating at last inspection: Requires improvement (Report published 12 December 2018).

Why we inspected: This was a planned inspection.

Enforcement: Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: We will continue to monitor this service and plan to inspect in line with our reinspection schedule for those services rated Requires improvement.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This unannounced comprehensive inspection took place on 9 and 12 April 2018. The last inspection took place on the 11 and 15 March 2016 when the service was found to be meeting the legal requirements. The service was rated as Good at that time. At this inspection we found breaches of the regulations. The service rating has therefore changed to Requires Improvement.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is required to have a registered manager and at the time of this inspection there was a registered manager in post, although they were on leave at the time of first visit of this inspection. We returned for a second day to spend time with the registered manager. 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 and associated Regulations about how the service is run.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes.

The premises were well maintained, clean and with no malodours. The service was registered for dementia care. There was some pictorial signage to support people, who were living at the service with some early dementia, who may require additional support with recognising their surroundings. The premises were regularly checked and maintained by the provider. Equipment and services used at Hamilton House were regularly checked by competent people to ensure they were safe to use.

Care plans were organised and contained information about each person’s needs. However, some information was not always accurate and complete. Care planning was reviewed regularly. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible. However, three fire escape doors were not opened easily and immediately and were not usable "without a key and without any specialist knowledge" in a fire situation as directed in the Regulatory Reform (Fire Safety) Order. This posed a potential risk to people living downstairs. The registered manager had addressed this concern on our second visit and ensured all fire escapes were easily opened in an emergency.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. There were no staff vacancies at the time of this inspection. There was a happy stable team of staff working at Hamilton House.

There were systems in place for the management and administration of medicines. People received their medicines as prescribed. Regular medicines audits were being carried out but these had not effectively identified that over 30 handwritten entries on to the medicine administration records (MAR) were not signed by two staff as directed in the medicines policy. This meant there was a potential risk of errors being made in the manual recording of medicines.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

People had access to activities. Staff provided a planned programme of activities supported by external entertainers. Some people went out into the local area.

The use of technology to help improve the delivery of effective care was limited. Mobile call bell pendants were not available to people. However, call bells were available in lounges, corridors and peoples bedrooms.

Staff were supported by a system of induction training, supervision and appraisals. Mandatory training was provided to all staff with regular updates provided. The manager had an overview of staff training needs.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies and procedures. However, these had not been reviewed or updated for some years. This meant there was a risk that staff were not always provided with current guidance.

People told us, “I feel very safe here,” “The bells are answered straight away” and “I don’t use the bell, I shout, but there is always someone there.” One staff member told us, “I am particularly aware of the residents with dementia and mental challenges and make sure I regularly check on them.”

Staff and management did not always act in accordance with the Mental Capacity Act 2005. There was some understanding of the principles of the Deprivation of Liberty Safeguards, however they were not always applied correctly. Records relating to this legislation were not always accurate.

The manager was supported by the provider and a team of motivated and long standing staff.

The staff team felt valued and morale was good. Staff told us, “I love my job and we are a big family here” and “I feel I can always get the support I may need, the door (to the registered managers office) is always open.”

There were some quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by both the registered manager and a member of the senior management team.

Not all people and their families had been asked formally for their views and experiences of the service provided. Some relatives and healthcare professionals had been asked to complete a survey of their views.

A few people had personal money held by the service. This allowed them access to small amounts of money to enable them to purchase items such as chocolate, cigarettes and toiletries etc.The records held did not tally with the amount of money held by the service. The registered manager had left an amount of their own private funds for people to access if needed.

Some records relating to recruitment were in the process of being transferred to a computer based system and had been taken out of the service for this to be done. We were given assurances by the registered manager that their recruitment processes were robust.

We found breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

After the comprehensive inspection the provider wrote to us to say what they would do to meet the legal requirements. We undertook this comprehensive inspection on 11 and 15 January 2016 to check they had followed their plan and to confirm that they now met legal requirements. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Hamilton House on our website at www.cqc.org.uk

Hamilton House provides care and accommodation for up to 35 older people, some of whom are living with dementia. On the day of the inspection 33 people lived at the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

One person said; “They are all very good at helping me.” A relative said; “If all homes were run like here we wouldn’t need any inspections!”

People were busy and were enjoying the company of the staff. There was a calm and relaxed atmosphere within the service. Comments included; “Staff are very kind.” A survey returned to the home said; “I think the care is exceptional.” People said they were happy living at the service.

People, relatives and visiting professionals were happy with the care the staff provided. They agreed staff had the skills and knowledge to meet people’s needs. People were encouraged and supported to make decisions and choices whenever possible in their day to day lives.

People had their privacy and dignity maintained. Staff were observed supporting people with patience and kindness.

People were better protected from harm as staff had completed safeguarding of vulnerable adults training. Staff had the knowledge on how to report any concerns and what action they would take to protect people. The registered manager had taken action where they thought people’s freedom was being restricted. Applications were made and advice sought to help safeguard people and respect their human rights

People were protected by safe recruitment procedures. Staff were supported with an induction and on-going training programme to develop their skills and staff competency was assessed. Everyone felt there were sufficient staff on duty.

People had visits from healthcare professionals. For example, GPs and district nurses, to ensure they received appropriate care and treatment to meet their health care needs. Professionals confirmed staff followed the guidance they provided. People received the care they needed to remain safe and well. For example, people had regular visits by district nurses to change dressings. A relative survey recorded; “I can’t believe the difference in his health since he moved in here-it’s great.”

People’s medicines were managed safely. Medicines were stored, and disposed of safely. Senior staff administered medicines, they confirmed they had received training and understood the importance of safe administration and management of medicines.

People who did not have capacity to make decisions for themselves were supported by staff to make sure their legal rights were protected. Staff worked with other professionals in their best interests.

People were supported to maintain a healthy balanced diet. People told us they enjoyed their meals and there was plenty of food available. We observed people, who required it, being supported at mealtimes.

People’s care records were of a good standard, were detailed and held people’s preferences.

People’s risks were considered, well-managed and regularly reviewed to keep people safe. Where possible, people had choice and control over their lives and were supported to engage in activities. Records were updated to reflect people’s changing needs. People and their families were involved in the planning of their care.

People and staff described the registered manager as approachable, available and supportive. Staff talked positively about their jobs and took pride in their work. Visiting professionals and staff confirmed the registered manager made themselves available and was very good.

The registered manager had an ethos of honesty and transparency. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

People’s opinions were sought formally and informally. There were quality assurance systems in place. Feedback was sought from people and their relatives to assess the quality of the service provided. Audits were conducted to ensure the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and, where there were areas for improvement, these were shared for learning.

We found that there were systems in place for obtaining consent from and acting in accordance with people's desires for how their care needs should be met. We found that the care needs of the people were met by good standard of care planning and these care plans were reviewed on a regular basis. The staff were seen to interact well with the people and displayed a good working knowledge of the people's individual care needs.

We found there was adequate nutrition and fluids available and there were nutritional supplements being used as prescribed. There was a choice of fluid available in the rooms and this was within people's reach and support was given as needed.

We found that there was a safeguarding policy in place and staff were suitably trained and supported to carry out their role as carers. They had received training in specific needs areas such as dementia and mental health that reflect the needs of the people living in the home.

We found that there systems in place to monitor the quality of the service and we found that the provider was compliant but there are a number of areas through the report that they might like to look at to ensure they continue to meet the desired standards

We talked with five people who lived at the home and observed care being provided. People using the service told us, 'I have everything I need, the staff are all very nice to me' and ' You cannot beat this home, the staff are excellent'.

Everybody we spoke with said staff were kind, thoughtful and always treated them with dignity and respect. They told us that staff listen to them, supported them and made them feel safe.

We saw that care staff at Hamilton House were attentive to people's needs and that people's healthcare needs were being met. Care staff knew people as individuals and there was a relaxed and friendly atmosphere at the home.

We spoke with eight staff who all told us they enjoyed working at the home. We found that some people living in the home had health conditions that made them vulnerable and in need of consistent care and surveillance. Staff told us that they felt there were enough staff on duty at all times to provide that level of care. Staff said that the management of the home were approachable and supportive.

Medication systems were managed safely to ensure that people using the service received medication safely.

We looked at documents related to care being provided and saw that they were well maintained, suitable for purpose and stored securely to ensure the confidentiality of people using the service.