Hampstead Court Care 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.

This is the first assessment for this service. This key question has been rated 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 provider was in breach of legal regulation 12 in relation to the ways people’s medicines were managed. 

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider made sure complaints and incidents were well recorded with follow up actions and outcomes. Senior staff had additional oversight of any reports conducted to investigate incidents and actions taken to remedy issues raised.

The service responded positively to people’s feedback and changes were made as a result. For example, comments from people regarding food led to changes to the menu and activities were added following suggestions.

Learning from incidents was also clear, with changes made to care plans and new risk assessments carried out made and information shared with staff as a training tool.

Safeguarding and health concerns were reported to relevant agencies promptly and with ongoing, open communication.

One person told us, “I have a pressure mat for my safety. I have fallen once and hurt my back, but they responded quickly.”

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.

Initial assessments for those moving into Hampstead Court Care Home were recorded in care plans and formed part of the ongoing reviews of care. It was also clear how this informed risk assessments for aspects of care such as falls risk and ensuring the necessary equipment was in place to minimise risks. This included easy to follow flow charts and inclusion of all relevant agencies.

Multidisciplinary team meetings took place regularly so that all people involved in a person's care had opportunities to discuss actions and progress. Professionals we spoke to advised that the service was well engaged in terms of both responding to advice they gave and also with seeking support when it was needed.

The service was able to recognise when they were not the most suitable placement for a person to live and were honest in communicating this with relevant involved people and professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had a clear safeguarding policy and reporting procedure. This enabled any trends to be picked up promptly and all concerns were recorded, progressed and actions followed through and all progress through a concern to be recorded and actions followed through.

The provider notified relevant agencies and followed up with these effectively and requesting further support where it was needed.

Staff demonstrated a good understanding of safeguarding risks and the circumstances of people who were at risk of abuse. Staff reported that the management team maintained an open culture where staff felt confident reporting concerns, contributing to the overall safety of the service.

They were clear of their responsibilities and knew how to raise concerns. Some staff were unsure of escalation points outside of home managers. We discussed this with the registered manager and they told us this information was displayed in a staff room and they planned to draw the attention of staff to where they could find the information if it was needed.

The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety.

Staff showed an understanding of the principles of the Mental Capacity Act 2005.

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 supported to live as independently as possible. They provider took steps to promote independence using suitable equipment. People were supported to take risks and make informed choices where it was their wish to do so and they had the mental capacity to make the decision. This was recorded and conversations repeated to ensure continued understanding as well as to allow opportunities for change.

The provider undertook risk assessments to ensure people were safe and supported. Alongside wider assessments people had individual risk assessments that reflected both their needs and wishes. These were regularly reviewed and updated.

One person told us, “I have a walking frame and they encourage me to use it. They do know what I can and can’t do”

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

The onsite maintenance team carried out daily checks to ensure the home was hazard free. This included monitoring of building temperatures and lift operation. Actions required were recorded in these checks and completion of actions noted.

Staff also carried out regular equipment safety checks. Call bells were available in all rooms, lounges, lifts, bathrooms and toilets. Staff responded to these bells in a timely manner and checks were carried out to make sure they were in working order.

Fire safety checks were carried out and records of regular tests of fire equipment were maintained. Staff had created personal plans for evacuation for each person. Those we reviewed were appropriate and accounted for individual needs such as reduced mobility.

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.

Staff recruitment files were complete. These showed the provider had undertaken checks which included relevant work experience, references and clear criminal records checks prior to commencing employment.

At the time of our assessment, the provider was planning to recruit a clinical lead and the activity team had recently been increased.

Staff training was up to date and staff undertook regular refresher training. There were sufficient staff on duty to meet people’s needs and keep them safe. Staff we spoke to told us they felt they had the skills and support to carry out their duties and that there were enough staff to allow this too.

Staff expressed they were happy with training opportunities offered, that internal progression was encouraged and all spoke positively about the service and support they received to do their jobs well.

We observed staff working collaboratively and it was clear from interactions we saw that staff knew the individual needs of the people they were providing care to.

One person said, “I have confidence in the staff to look after me well. They are supportive and go out of their way to help me”

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.

We observed staff using appropriate personal protective equipment (PPE), such as gloves and aprons when providing care. Staff told us they had no concerns about availability of PPE. People we spoke to also told us that staff use appropriate PPE when supporting with personal care, “They always have aprons and gloves if undertaking personal care.”

There is a suitable infection prevention policy in place which includes directions on minimising risk of transmission.

The home was visibly clean and hazard free with no malodours. We observed a continued presence of housekeeping staff throughout the day.

There was a new head housekeeper in post when we visited who oversaw the housekeeping team. The daily cleaning routine was clearly recorded and any points of note responded to and actions noted and followed up. The registered manager had oversight of theses audits.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always managed in line with national guidance and legislation. Some time critical medicines, such as pain killers which must be given at the prescribed time to manage pain and symptoms were not always given as prescribed. We reviewed the medicines administration charts for people who required their medicines to be given at an exact time. We saw these medicines were not always given at the prescribed time..

We saw an incident where a person was discharged back to the home from hospital and their medicines records were not updated when there had been a change in their medicines regime.. This resulted in the person not having effective pain relief for 7 days when they returned back to the home.

We saw an instance were a liquid medicine that had recently expired had been administered to a person. This could have placed the person at risk of avoidable harm.

The provider did not have effective arrangements to ensure medicines that have been discontinued, were always disposed of safely and in a timely manner. For example, we found that a medicine that had been discontinued since 2024 was still stored in the home.

Records of controlled medicines were also not maintained appropriately. In one case the count of a medicine that was discontinued was zeroed when the medicine was still present in the home and had not yet been disposed of.

The service had a process for ensuring medicines given covertly (without people’s knowledge) were safe to administer and this was in line with legislation. This included advice and support from family members, the person’s GP and the local pharmacy. However, the process was not robust in ensuring medicines prescribed after initial authorisations for covert delivery were suitable to be given in this way.

Medicines given topically were recorded on a topical medicines administration record (TMARs). Whilst staff knew how to support people with their topical medicines, we saw that the TMARs did not always contain the prescribed information about where and how to apply medicated creams. Furthermore, we saw gaps in administration records where applications had not been recorded.

The service had an effective process for ensuring that people’s medicines were ordered and delivered in a way to ensure people had enough of their medicines. Medicines, including controlled drugs, were stored securely with access only available to authorised staff.