Hamilton House is a care home which offers care and support for up to 36 predominantly older people. At the time of the inspection there were 36 people living at the service. Some of these people were living with dementia. The service occupies a house over three floors with a passenger lift and stair lifts for people to access the different floors.

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

We carried out an unannounced comprehensive inspection of this service on 9 and 10 June 2015. Breaches of legal requirements were found. This was because people’s care plans did not detail people’s individual care needs sufficiently and people’s risk assessments did no link to their care plans.

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

We looked at twelve of the rooms and spoke with four people in one to one interviews and others during mealtimes. We also spoke with seven members of staff, the Registered Manager, owner, four family members and two professionals with direct roles with people living at the home.

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 (the Care Quality Commission) carried out this inspection as part of our scheduled inspection programme.

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.

Some of the people living in Hamilton House have limited communication and were unable to communicate with us. However, we did meet with all of the 34 people living in the home and observed the interaction between them and the staff working in the home. Information about peoples’ experiences in the home was given to us by two visiting professionals, three visitors to the home and staff working in the home.

During our visit we observed people enjoying their meals, going about their everyday routines and relating well with the staff supporting them.

We saw staff treating people with dignity and respect at all times, communicating clearly and sensitively with people, and responding promptly to the differing needs of people in the room. ‘The staff are very good’, we were told by one person in the conservatory.

Most of the people who live at Hamilton House come down from their room for meals, a few wish to remain in their own rooms. People who needed help to eat their meal were given that help sensitively and discretely. We saw that people were given alternative food according to their dietary needs.

We spoke to two health and social care professionals about Hamilton House and all spoke positively about the home. One said, ‘They always keep us informed’, with a relative writing on a returned questionnaire, “I am extremely lucky to have found such an excellent home”. One person living in the home said, “The staff are very kind to me”.

We inspected the service on the 9 and 10 June 2015. The inspection was unannounced.

We last inspected the service on the 5 July 2013 and found no concerns.

Hamilton House provides residential care without nursing for up to 35 older people. People living at the service may be living with dementia or have mental health issues. There were 34 people living at the service when we visited.

A registered manager was in post. 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.

People had risk assessments in place however these were not always clearly linked to people’s care plans. Risks associated with people’s individual needs were not formally recorded to ensure people were protected and staff had the full information to meet people’s needs.

People’s care plans did not detail people’s individual care needs sufficiently to ensure staff knew what care to deliver. The registered manager and staff were extremely knowledgeable about people, their needs and the unique ways they needed to meet people’s needs. When we spoke with staff they were consistent in their approach in meeting people’s needs. Paperwork however did not always demonstrate how to deliver care safely and records did not always reflect care and treatment given.

People’s medicines were administered safely however the records were not always evidencing this. For example, staff were not being shown where and how to administer people’s prescribed creams safely. They were not then recording the creams had been applied. Staff were not recording people’s ‘as required’ medicines with the amount and time this had been administered.

Not all staff followed safe infection control practices. However, these were addressed immediately by the registered manager. We have recommended the registered manager reviews the appropriate guidance on infection control practices in care homes.

The registered manager had not submitted the legal required notifications to CQC to inform us of incidents relating to people living at Hamilton House.

People felt safe living at Hamilton House. People and family members felt confident in the skills and attributes of the staff to provide a good level of care. People were looked after by staff who treated them with kindness and dignity. People were involved in planning their care and making choices about how they wanted their care to be delivered. There were sufficient staff to meet people’s needs safely and they were trained to ensure they provided a good level of care. Staff were recruited safely. Staff understood how to keep people safe from harm and felt any concerns would be taken seriously.

People had their nutritional and health needs met. People were involved in developing the menu. Their dietary requirements were catered for and staff followed advice on ensuring people had their food prepared to reduce the likelihood of choking where this was important. People could see their GP and other health professionals as required. Any concerns about people’s health were addressed quickly. Health professionals were complimentary about the registered manager and staff’s ability to meet people’s needs.

Staff provided times for people to remain socially active which reflected their personal history. People had their faith needs met.

People had their complaints and concerns responded to appropriately and the registered manager ensured people were happy with the outcome.

There was a clear management structure in place with clear roles and responsibilities. People, family members and staff spoke highly of the registered manager and their ability to manage the home. The registered manager had recently introduced a new management structure following a review.

The registered manager had systems in place to ensure people, family, staff and professionals were involved in monitoring the quality of the service. The registered manager demonstrated a commitment to a high level of care for all people living at Hamilton House.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.