Hamilton's Residential 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to safe care and treatment and staffing. Concerns included the management of risk, medicines management, infection control and staff training and competence.

This service scored 38 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. There were processes in place to record accidents and incidents. However, this process had not always been effective in identifying patterns and trends. Staff had completed forms on the electronic documentation system, but they had not always included all the required information or details of what had happened. The provider had an electronic system to analyse accidents and incidents to identify patterns and trends. However, there was no evidence this had been done or used to mitigate risks to people. Care plans had not been updated following accidents to reduce the risk of them happening again. People told us they felt safe living at the service and would speak to staff if they had any concerns.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. The provider did not always make sure there was continuity of care, including when people moved between different services. When people wanted to move into the service, people’s needs were assessed to check staff could meet them. When people were admitted to the service, a care plan was not always available for staff to follow. Staff told us they spent time getting to know people and used their skills in the absence of a care plan. Staff told us when people were transferred to hospital, staff printed off an emergency pack from the electronic care plan system, to send with people. However, there was a risk people would not receive the support they needed due to the lack of up to date information in the care plans.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had processes in place to report safeguarding concerns to the local authority. However, records were not accurate. When concerns had been raised such as wound development, investigations were hampered as records were incomplete. The new manager had been working with the local authority to investigate concerns. They told us this had been difficult as there were no records, and staff had been unsure of details. Staff told us they had received safeguarding training and could describe the action they would take. Staff explained they had not always been confident the previous manager had acted on their concerns but were more confident in the new manager.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. At our last inspection, there were shortfalls in the management of risk. There continued to be shortfalls at this assessment. Potential risks to people’s health and welfare had not always been assessed. Where risks had been identified, care plans lacked personalised and relevant guidance for staff to follow to reduce the risks to people. For example, some people were living with diabetes. There was generic guidance in place, including to give a medicine via injection if the person was unable to take sugar by mouth. People had not been prescribed this medicine and staff were not trained to administer it. Audits had identified some people had lost weight over the previous 6 months. This had not been reflected in their care plan or assessment tools. Appropriate action had not been taken to reduce the risk of further weight loss. When people were at risk of skin damage, specialist equipment such as pressure relieving cushions were not always in place. Where equipment was in place, it was not always used correctly. For example, some people had pressure relieving mattresses. Staff had not checked the settings were correctly set to each person’s weight. Staff had identified some people required a pressure relieving cushion to sit on. However, these had not always been sourced, or were flat and not fit for use. This placed people at risk of skin damage. Some people were prescribed medicines to thin their blood. This placed them at risk of bruising easily or excessive bleeding such as after a fall or head injury. There was no guidance for staff about what action to take if people had a fall. Staff told us they relied on their knowledge to support people when there was no guidance available. This placed people at risk of avoidable harm.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. During the assessment, we identified significant shortfalls in processes to keep people as safe as possible during a fire. People did not always have personal emergency evacuation plans (PEEP) to guide staff during an emergency. Where PEEP’s were in place, they did not contain up to date information. One person’s PEEP had not been reviewed since May 2024. They were now bedbound and requiring a different strategy with different support to evacuate safely, which was not in the plan. The provider's evacuation policy instructed staff not to use the stair lifts to evacuate people. There was no equipment in place, such as evacuation chairs, for staff to use to evacuate people safely. The provider had a fire evacuation plan. However, not all staff were aware of the information in the plan. There was only one copy of essential documentation including the PEEP’s. These were locked away at night and not easily accessible to staff in an emergency. Following our assessment, the provider and manager took immediate action to complete an evacuation drill and a new fire risk assessment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always ensure staff received effective support, supervision and development. Staff did not work together well to provide safe care that met people’s individual needs. There were no effective processes in place to ensure staff had the right knowledge and skills to support people safely. New staff had not received an induction when they started at the service. A staff member who had recently been employed told us they had no formal induction. Although they had completed training in their previous place of employment, they had started to work with people without completing the online training. The provider had not assessed their skills or competence to do the role. The training records showed staff had not always had the training required to support people. There was no record staff had received training to support people for example, with catheter care, pressure area care, nutrition or infection control. There were 7 care staff who had not received practical moving and handling training. Competencies had not always been checked, only staff competency to administer medicines had been completed. Audits were completed on staff training, however, these had not identified the shortfalls found at this assessment. There were enough staff on duty to meet people’s needs. However, staff did not always know people well. On the first day of our assessment, some staff had started at the service the week before and were working independently. There had been a large staff turnover under the previous manager, and large amounts of agency staff had been used. The provider told us they had not initially identified there had been an issue, but they were now employing staff. There was a risk people were being supported by staff who did not have the skills to support them safely.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There were no effective processes in place to monitor infection prevention control (IPC) and take appropriate action. The chairs within the communal lounge were fabric. There were 2 chairs which were visibly not clean and smelled of urine, staff had told us they had not been able to clean them. The provider told us they supplied a chemical cleaner for staff to use. However, these cleaning liquids did not have anti-bacterial or anti-viral properties to make sure cleaning was effective. We observed a foam mattress which had splits in the plastic covering and could not be cleaned properly. Staff had not recognised this as an IPC risk and were putting the mattress into storage to be used at a future date. The quality lead was responsible for keeping policies up to date and completing audits. However, the audits had not identified the shortfalls found at this assessment including staff not receiving IPC training. The provider’s policies did not reflect current Government guidance published in April 2024 in relation to visiting during an infectious outbreak. The provider was not aware visitors should be given the option to visit during an outbreak, unless there is a specific reason.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. At our last inspection, medicines had not been managed safely. There continued to be shortfalls at this assessment. Some people were prescribed medicines on a ‘when required’ basis such as pain relief. There was no guidance for staff about when to give the medicine, how often and what action to take if the medicines were not effective. Some people declined to take their medicines. There was no guidance for staff about what action to take when this happened., This had not been recorded in people’s care plans. Some medicines people were prescribed had side effects such as excessive bruising. There was no guidance about what action to take if they noticed this. The processes in place to order, store, administer and dispose of medicines did not always follow best practice. There was no record of medicines which had been disposed of and the reason why. There was a risk it would not be identified when people were not receiving their medicines as prescribed and the reason why, so action could be taken. Some medicines require to be kept at certain temperatures to remain effective. There were no records of the temperature in the medicine storage room or fridge for 6 days before our inspection. There were large gaps in the records which had been maintained. The provider could not be assured people’s medicine was kept in the required conditions.