Hamilton House 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to people's safe care and treatment in respect of risk management and infection control to prevent harm to people. 

This service scored 56 (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 positive culture regarding learning from events to prevent harm to people. Lessons were not always learnt to continually identify improvements and ensure good practice. Although lessons learnt were recorded, we found they were not fully embedded to ensure improved practice and prevent harm to people. For instance, we found a lesson learnt was recorded in March 2025 to ensure staff followed repositioning regimes to prevent pressure damage however, we found this was not routinely the case.

However, staff told us they knew how to report concerns about people’s safety. They felt able to raise concerns with the manager and felt they would be listened to, and action taken. Daily meetings were held with the manager or person in charge. These were opportunities to share any learning points to prevent harm to people.

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.

People and their relatives told us the staff worked well with external professionals. Comments from people included, “Generally, I am fine and don’t need to see any other medical staff. I am sure if I need hospital appointment somebody would be available to come with me. I do have regular chiropodist, hairdresser and sometimes manicure”. Another person told us “They [staff] listen when I say I am not well…they always act either calling GP or if they can help with some tablets, they do that.”

Systems were in place to ensure people were assessed prior to coming to live at the service. Staff had access to information about people when emergency services were called. On admission to hospital, staff ensured regular contact with the acute staff was maintained, to support a safe discharge back to the service.

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.

People told us they were safe. Comments included, “I do feel safe here primarily because of plenty of people around, being alone is not for old people like us, we are now in need of as much helps as possible”, “What is best feeling is that I am in a nice enough place which is fulfilling all my needs and that my family know I am in a safe place” and “I feel safe with staff and they do come and check on me, if I am not downstairs, I sleep well.”

This was supported by what relatives told us. Comments included, “Staff are working so hard to keep not just my relative but all other residents safe, healthy and best possible way” and “We have a good working relationship with Hamilton House Care Home, we know she is safe and well looked after, she has everything she needs and attention and care nobody else could offer.”

Relatives told us when safeguarding concerns or abuse were highlighted, they were kept fully informed and updated. We found the manager and staff worked well with the local authority to ensure potential abuse was reported and investigated swiftly.

Staff who provided feedback demonstrated a good understanding of how to safeguard people from abuse. Staff told us they would not hesitate to raise concerns to the manager, and to external parties if needed. Staff had received training on how to protect people from abuse.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA. We observed some people had restrictions placed on their movement. Where restrictions were in place, these were lawful. For instance, bed rails or lap belts on wheelchairs. We found people and staff had access to information about how to raise safeguarding concerns. However, we found improvements were needed in recording decisions made in people’s best interest.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were not routinely and consistently protected from potential harm. Individual risk assessments were in place to protect people when receiving care and support. However, we found these were not always followed. For instance, one person on restricted fluids had exceeded the recommended amount. Other people who had a fluid target to reach each day, did not always reach this, which increased their risk of dehydration.

People’s care plans were not always clear about how staff should manage pressure damage to skin. Repositioning charts did not routinely prompt staff on how frequently a person needed to move position. In addition, we found one person's care plan had contradictions on the frequency they needed to be turned. One section stating 2 hourly turning was needed, another section stating 4 hourly turns. However, records did not routinely demonstrate this occurred.

We found some people had additional equipment [barriers] in place to prevent unauthorised people entering their room. We found and the provider confirmed risk assessments had not always been written for the use of these.

However, staff told us they found risk assessments supported them to understand people’s needs. We found risk assessments were updated when people’s needs changed.

The manager and nursing staff held clinical risk meetings to monitor changes in people’s health. However, they did not always pick up the concerns we had.

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment and facilities supported the delivery of safe care. People were not routinely and consistently protected from potential risks. The provider had failed to identify, assess and do what was reasonably practicable to mitigate risks to people.

People were placed at a higher risk of ill health due to poor management and storage of harmful chemicals. For instance, dishwasher liquid and hand sanitiser readily accessible and could be ingested by some people with cognitive impairments. In addition, we found other potential risks to people which included a ligature risk in a bathroom and readily accessible medical gloves in corridors. The manager and provider had failed to identify these as potential risks. No risk assessments were in place. However, the manager and provider responded swiftly to our feedback.

People were at an increased risk of harm from fire. We found an overuse of extension leads throughout the home, some of which had the potential to overheat due to the overloading of extension leads (one extension lead plugged into another extension lead). The use of extension leads had been highlighted in a previous fire safety assessment by Buckinghamshire Fire and Rescue in 2023 and a fire risk assessment dated November 2024. One recommendation was to limit the use of extension leads, we found this was not the case. However, the manager and provider responded swiftly to our feedback to minimise use of extension leads and improve electrical safety. In addition, we found one person’s personal evacuation plan did not contain accurate information in which room they resided in.

During the assessment the home's kitchen was being refurbished, and a temporary kitchen space was being used. On the first day of assessment, we observed an electrical fly killer plugged in next to a tap, the provider had not identified this was an electrical hazard. A risk assessment was in place for the use of the temporary kitchen, but it did not contain sufficient information to mitigate risk and prevent harm from occurring.

On the second day of assessment, we found the kitchen unlocked and unattended, with pans of hot food cooking on the hob and sharp knives accessible. This placed people at risk of harm as there was no restriction on them being able to enter the kitchen and come into contact with these potential hazards.

People were not routinely supported by staff who had consistently been recruited safely. Safe recruitment practices were not always followed. Staff files did not always include evidence the service had checked gaps in staff employment history. This had been identified in a recent audit by the provider, but no action had been taken.

Information had been obtained from external agencies who supplied temporary staff to the home, however we noted the training information for an agency worker who had recently worked was not up to date, this had not been checked by the provider.

People we spoke with told us they had some concerns about the level of staffing. We heard “I don’t think there is enough staff, we tell them at the meetings to employ more staff” and “I do feel safe here, but sometimes staff don’t check on us, it wouldn’t hurt that they come and check every now and then that we are okay”.

Relatives commented "I don’t think there is the same amount of staff as before, maybe it’s only my perception to see a big drop, I only noticed because we wait sometimes 10 to 15 minutes for the door to be open and wait for somebody to let us out” and “The place is okay, maybe understaffed and [family member] often says nobody checks on [them] when [they] are in the room, I was there the other day and my whole visit I didn’t see any staff passing by [family member] room”.

However, we observed people were supported in a timely manner. On the second day of our assessment an emergency bell was activated, and we observed staff responded to this quickly to prevent any further harm to the person.

Staff told us they were confident in their role and they had received all the suitable training required to undertake their role. The home operated a champion role for staff. Staff had been assigned to be a lead in a particular role for instance, in infection control and safeguarding.

Training compliance was monitored by the provider to ensure staff had the right skills and knowledge to support people. Where poor practice was identified, the provider took swift action to support staff to improve skills or ensure people were safe.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. One person told us “It is not surgically clean but it’s clean enough, it’s homely. I like my room, and I made it my home.” A relative told us “I expected maybe a bit cleaner environment, everywhere I look it can do with a bit of a clean-up, my relative’s room windows look dusty.”

Systems were not effective to ensure food items were safe to eat. We found fridges and a microwave were not maintained in a safe way, they were in need of cleaning. We found food items were not in date or not dated when opened to ensure they were used prior to expiry date. We provided this feedback to the manager. We found there was little oversight of this to ensure remedial action was taken in a timely manner.

We found areas of the home were in need of a deep clean. Many areas which were not used on a daily basis were clearly dusty and housed many cobwebs. Some bathroom areas which were not used but freely accessible to people had malodours and were not clean.

However, staff undertook infection control training as part of their mandatory training. We saw staff consistently used personal protective equipment (PPE), such as disposable gloves and aprons, when they carried out personal care or assisted people at mealtimes.

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.

People who required support with the administration of their prescribed medicines had support from staff who had been deemed competent by the provider.

We observed medicine administration. We found people were supported by staff who demonstrated professionalism, patience and knowledge. People were given time to take their medicines. Where people demonstrated reluctance to take their tablets, staff ensured they returned to them at a later time to offer the medicine again.

People told us they received their medicines when they needed them. Some people were prescribed ‘as required medicines’, additional guidance was available for staff on when and how it should be administered.

Senior staff carried out regular checks on medication records, stock and procedures. We looked at stock records for medicines, included those which required additional storage requirements due to the risk of abuse. We found records were accurate and up to date. The areas where medicines were stored were clean and tidy.