Hamilton House is a nursing home which provides accommodation, personal care and nursing care to 60 older people, some of whom were living with dementia. The home has three floors, with a passenger lift which gave access to all floors and all bedrooms had en-suite facilities. At the time of the inspection, 54 people were living at the home.

The inspection was unannounced and took place on 22 and 23 October 2018. There was a registered manager in place. 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.

At our last inspection, in April 2018, we identified breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Best practice guidance in the management of diabetes was not always followed and quality assurance systems were not always effective. At this inspection, we found action had been taken and there were no longer any breaches of Regulations.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made. Therefore, this service is now out of Special Measures.

There was a registered manager in post at the service. 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.

People felt safe living at the home. Staff knew how to identify, prevent and report abuse. They assessed and managed individual risks to people and risks posed by the environment effectively.

Arrangements were in place for the safe management of medicines. People received their medicines as prescribed. The home was clean and hygienic and staff followed best practice guidance to control the risk and spread of infection.

There were enough staff deployed to meet people’s needs. Appropriate recruitment procedures were in place and pre-employment checks were completed before staff started working with people.

People’s needs were met by staff who were competent, trained and supported in their role. Staff acted in the best interests of people and followed legislation designed to protect people’s rights and freedom.

People’s nutritional and hydration needs were met and they received appropriate support to eat and drink enough. Adaptations and improvements had been made to the home to make it supportive of the people living there.

People were supported to access other healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care.

People were cared for with kindness and compassion. Staff used supportive techniques to communicate effectively with people.

Staff protected people’s privacy and dignity. They encouraged people to remain as independent as possible and involved them in planning the care and support they received.

People’s needs were met in a personalised way. Each person had a care plan that was centred on their needs and reviewed regularly. Staff empowered people to make choices and responded promptly when people’s needs changed.

People had access to a wide range of activities based on their individual interests, including regular access to the community. They knew how to make a complaint and felt able to raise concerns.

Staff took account of people’s end of life wishes and preferences. They supported people to remain comfortable and p

Hamilton House is a nursing home which provides accommodation, personal care and nursing care to 60 older people, some of whom were living with dementia. The home has three floors, with a passenger lift which gave access to all floors and all bedrooms had en-suite facilities. At the time of the inspection, 48 people were living at the home.

The inspection was unannounced and took place on 19 and 20 April 2018. There was a registered manager in place. 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.

At our last inspection, in September 2017 we identified widespread and systemic failings and rated the service ‘Inadequate’ overall. We identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. Medicines were not managed safely; risks to people were not managed effectively; staff did not always act in an open way when accidents occurred; allegations of abuse were not always investigated; safe recruitment procedures were not followed; staff training was out of date; people’s rights were not protected; care plans did not always reflect people’s needs; quality assurance systems were not effective; and notifications of important events were not always submitted.

Following the inspection, we placed the service in special measures in order to monitor it closely. The provider wrote to us detailing the action the intended to take to meet the regulations and sent us weekly updates of their action plan.

At this inspection, we found improvements had been made under the leadership of a new management team. However, we identified that quality assurance systems needed further development and time to become fully embedded in practice. There continue to be two breaches of regulations in relation to safe care and treatment and good governance.

The provider had clear recruitment procedures in place, but these were not robust and were not always followed.

People were supported to receive their medicines safely and as prescribed. However, there was insufficient guidance about two medicines that were used on an ‘as required’ basis and the temperature of medicines that needed to be refrigerated was not monitored effectively.

Staff were suitably trained and supported in their roles. However, we found some nurses did not follow evidence based practice when supporting people with diabetes or pressure injuries.

Each person had a care plan that was centred on their needs and reviewed regularly, although we found some care plans contained conflicting information.

People felt safe living at the home. Staff knew how to identify, prevent and report abuse. They assessed and managed risks to people and risks posed by the environment effectively.

Individual and environmental risks to people were managed effectively. The home was clean and hygienic and staff followed best practice guidance to control the risk and spread of infection.

There were enough staff to meet people’s needs in a timely way. They acted in the best interests of people and followed legislation designed to protect people’s rights and freedom.

People’s dietary needs were met and they received appropriate support to eat and drink enough. Adaptations had been made to the home to make it supportive of people living with dementia.

People were supported to access other healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care.

People were cared for with kindness and compassion. We observed positive interactions between people and staff throughout the inspection, with one isolated exception.

Staff protected peopl

Hamilton House is a nursing home which provides accommodation, personal care and nursing care to 60 older people, some of whom were living with dementia. The home has three floors, with a passenger lift which gave access to all floors and all bedrooms had en-suite facilities. At the time of the inspection, 55 people were living at the home.

The inspection was unannounced and took place on 4 and 6 September 2017.

There was not a registered manager in place. 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. The provider had recruited a new manager who was due to start work four weeks after the inspection. At the time of the inspection, the service was being managed by an interim manager who had been in post for four weeks.

At our last inspection, in August 2016, we identified breaches of Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. ‘As required’ medicines were not managed appropriately and quality assurance systems were not always effective. At this inspection we found continued breaches of these regulations, together with other concerns.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There were widespread and systemic failings identified during the inspection. Quality and safety monitoring systems had not been fully effective in identifying and directing the service to act upon risks to people who used the service and ensuring the quality of service provision. The service has a history of not being able to make and sustain improvement and has been in continual breach of regulations since first being registered with CQC in 2011.

A comprehensive review of the service by the provider’s governance team, in July 2017, had identified widespread deficiencies. This had led to the development of an action plan that was being implemented by the interim manager. However, we could not be assured that the work started by the interim manager would be continued under the leadership of the new manager.

Staff had not always notified CQC of significant events that occurred in the home. Neither had they followed legisl

We carried out an unannounced comprehensive inspection on this home on 22 and 26 January 2015. Three breaches with the legal requirements of the 2010 Regulations which corresponded to the 2014 Regulations were found. The administration of medicine practices in the home were not safe as the protocols for take as necessary (PRN) medicines did not include sufficient detail. Staff received formal supervision, but this was not planned and was delivered on an ad hoc basis. Care plans did not consistently or sufficiently detail people’s needs to ensure their welfare and safety at all times. At the last inspection on 22 and 26 January 2015 we asked the provider to take action to make improvements and the service had addressed these actions.

We undertook this unannounced comprehensive inspection on 15 August 2016 to check that they had followed their plan and to confirm that they now met legal requirements. At the inspection on 15 August 2016 we found the provider had taken some steps to address these concerns and had introduced clear protocol documents to be implemented and completed by staff for the administration of PRN medicines. However we found this practice was not embedded in the service. Whilst information contained within care plans remained inconsistent people were receiving the most up to date care. Improvements had been made with the monitoring and completion of staff supervision and appraisals.

Hamilton House is a nursing home which provides accommodation, personal and nursing care to 60 older people, some of whom live with dementia. The home has three floors, with a lift which gives access to all floors. At the time of the inspection 59 people lived at the home.

There was a registered manager in place at the home. 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 felt safe and staff knew how to keep people safe. Medicines administration was safe however there were still concerns with the lack of information regarding (as required) PRN protocols. Risk assessments were in place and staff were aware of the risks to people and themselves. There were sufficient staffing levels and safe recruitment practices had been carried out.

Staff felt well supported and received regular supervision and appraisal. Training plans were in place and staff received regular training however staff did not always feel the training gave them the skill or confidence to support people living with advanced stages of dementia and behaviours that were deemed to be challenging. Staff showed a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS were in place appropriately for people.

People’s nutritional needs were being met however people may not always be encouraged to eat independently. People were given a choice of meals; however people with dementia were unable to recall the choice of meal they had made from the previous day.

People were supported to access healthcare services.

Staff were kind, caring and respected people’s privacy, dignity and independence when providing them personal care. There were good interactions with the majority of people.

Where possible people made their own decisions about their care and were supported to do so if they were unable to make these decisions.

Care plans were in place and an assessment of need was completed for people when they were admitted to the home. People’s needs were met but care plan information was inconsistent and people’s turning charts were not always completed accurately. Care plans were personalised and included people’s preferences.

Activities took place but we could not be sure they were always meaningful to people. People who remained i

The home has a manager in post who has submitted an application to us to become the registered manager of the home.

One inspector carried out this inspection. At the time of our visit 44 people were being accommodated at the home over three floors.

The focus of this inspection was to follow up a warning notice which had been served following our last inspection with respect to outcome 2, consent to care and treatment. We checked the provider had arrangements in place for obtaining and acting in accordance with consent of people to the care and treatment people received.

During this inspection we found the provider had taken appropriate action with regards to ensuring people had capacity to consent to care and treatment. Where people were deemed as not having capacity and having their liberty deprived appropriate arrangements had been put in place.

In this report the name of a registered manager appears who was not managing the regulatory activities at this location at the time of the inspection. The home has a manager who has informed us they will be applying to register with the Commission to become the registered manager.

During this inspection we looked at what progress the home had made with regards to the associated outcome areas where we had identified non- compliance. We found that the home had made progress in nearly all the areas previously identified. However whilst we found progress had been made we found that there were still areas of non–compliance.

Our inspection team was made up of two inspectors and a specialist advisor. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, looking at records, speaking with eight relatives, 11 staff members supporting people, the manager, deputy manager and the regional manager.

Is the service caring?

Most of our observations during this inspection demonstrated people were treated with kindness and compassion. Relatives spoken with all praised the work of the care staff and spoke about their patience and kindness. We found some of the agency staff used in the home did not have the same set of skills as the permanent staff. On two occasions we were told “I am just agency” as a way of explaining they did not know the needs of people they were caring for. We found people were treated with dignity and respect. We found it difficult with all people to establish that their independence was promoted at all times.

Is the service responsive?

We found people’s care records were personalised and we observed that family members had been involved with giving information regarding the person’s background likes/dislikes and preferences. We found for some people they had good care plans but they had not been reviewed and were not reflective of the person’s current health and care needs. For some people we could not establish that the care plan was being followed by staff for the delivery of care to the person.

Is the service safe?

We found that staff had a good understanding of raising safeguarding concerns and were pleased to hear staff had recently raised a safeguarding concern with the management of the home. The management of the home had acted appropriately and contacted all the relevant agencies to ensure people were safe.

The analysis of accidents and incidents had improved. However we did see some areas of concern with the environment and people’s furniture and were concerned these had not been picked up by quality assurance.

We found that were adequate staffing levels in the home.

We could not see people had been assessed appropriately under the Mental Capacity Act 2005. We found that at times people could be considered to be deprived of their liberty but appropriate referrals or assessments had not been undertaken. We found that the environment of the home meant some people were restricted in their movement. We also noted a problem with one person’s medication records which had not been picked up by monthly quality monitoring of medication in the home. The home was still using a high percentage of agency staff on a weekly basis.

Is the service effective?

We found that assessments had been carried out before people moved into the home. People had care plans however we were not assured that these were all up to date or reflective of all people’s needs. We found examples of where people’s care plans expressed a preference but this was not being followed by staff. For example a care plan stated the person liked to get out of bed and sit in their chair on a daily basis. However we could not see that this was happening on a daily basis.

We found that training and supervisions had started for staff and there had been progress made in this area. However it was acknowledged that here was still further progress to be made in these areas.

We could see that people had assessment of their nutritional needs and care plans had been developed. However we could not be assured for all people that these were kept up to date or from records that they were followed by staff.

Is the service well led?

The service has been working with other professional agencies who have been monitoring the home. They told us the home has been open and there has been good communication.

Staff spoken with made positive comments about the manager of the home. They told us they were always available and their door was open. They told us they welcomed ideas of how things could be improved. This view was echoed by relatives we spoke with, who made positive comments about the new manager of the home.

We were shown a dependency tool and it was explained how the needs of people were matched to the staffing levels. However staff still talked of moving around on a daily basis to meet people’s needs. A member of staff advised us there is enough staff but sometimes it just needs a bit more organisation to make sure are where they work best.

Since our last inspection on 8 July 2013 the home has a new manager, however they are not yet registered with the Commission. They advised us they would be applying for registration. The manager had been in post for two months. They told us they were aware of the shortfalls in the home and had found prior to their appointment there had been no quality assurance monitoring in the home. They advised us they had started to put quality audits in place with the support of two regional managers.

We spoke with three visitors who told us the staff members worked very hard. They told us however they did not think the staffing levels were adequate to meet the needs of people living at Hamilton House. They told us the staff members were kind and caring but there was not enough of them on duty. Two told us they came in on a daily basis to ensure their relatives were well looked after.

We found that staff members were not able to meet the needs of people with the present staffing levels on some shifts.

Records indicated staff had not received training in some of the vital areas including dementia, mental capacity and end of life care.

Observations on the day showed us people were not always treated with respect and dignity. We found that staff interactions were sometimes rushed.

We found medication procedures in the home needed improving.

We saw some good examples of where people's privacy and dignity was maintained. For example when personal care was carried out, people's privacy was considered. At the meal time we saw staff respond to people in a caring and calm manner. We also saw some examples of where people were not treated with respect and their independence maintained. For example one staff member did not treat people with respect at meal times. Not all staff knew to respond to one person by their preferred name. We received a mixture of positive and negative comments from people and their visitors.

People had care plans which gave members of staff details on they should be cared for, but the lack of recording made it difficult to establish if the care plan was followed. People and their visitors gave us a mixed picture of their experience of living at Hamilton House. Some felt it was 'excellent' whilst others reported it was 'so so'.

We found that at the time of our inspection the home was using agency staff on a daily basis to cover the core hours on the duty rota. We received mixed comments about the staff from people and their visitors. We found that staff were not receiving support and supervision on a regular basis. Staff had not received all the training they needed to carry out their role safely.

The lack of records maintained on each person made it very difficult to ensure all their care needs were being met.

During this visit we looked at the care records of eight of the 54 people living in the home. We spoke with people living in the home, We spoke with staff and four visitors on the day, all who spoke positively about the care their relative received.

People were treated with respect and their dignity was promoted. People and visitors told us staff were respectful of people’s privacy. One visitor told us, “Staff treat Mum as an individual, they have a personal connection and the respect and dignity offered to Mum is marvellous”

People had an assessment completed before they moved into the home and a care plan was developed from this. We were able to establish care plans were reviewed and necessary risk assessments had been completed and reviewed. Records were not always fully completed and it was difficult to establish the extent of each persons social activities.

People told us they felt safe in the home and able to discuss concerns with staff. Staff were aware of the safeguarding and whistle blowing policy.

Staffing levels met the needs of people. People, visitors and staff all told us they felt the staffing levels in the home were adequate to ensure the needs of those living At Hamilton House could be met.

People told us they knew how to complain and felt their complaint would be dealt with efficiently. The home maintained a complaints log, making it possible to establish they dealt with complaints in a satisfactory manner.

This unannounced inspection took place on the 22 and 26 January 2015. Hamilton House is a Nursing home which offers personal and nursing care to 60 older people, some of whom live with dementia. The home has three floors, with a lift which gives access to all floors.

At a previous inspection on 28 March 2014 and 2 April 2014 we found continued non compliance with the regulations and issued warning notices regarding respecting people, care and welfare, staffing issues quality assurance, consent and records.

We inspected in June 2014 and found there had been an improvement with all the Regulations where warning notices had been served. However there was not sufficient improvement to have reached compliance and the breaches remained. Compliance regarding the issue of consent had not improved and a warning notice was served.

On 28 October 2014 we inspected and just looked at the issue of consent, with regards to the warning notice that had been served. We found the provider had improved and was compliant with this Regulation.

The home has a 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 2008 and associated Regulations about how the service is run.

At this inspection, we found that staff had an understanding of abuse and what action they should take if they felt someone was not receiving safe care. Staff knew there were safeguarding policies and procedures but there was some confusion as to where these were located and what external agencies should be informed. Risk assessments relating to people were mainly well completed and had been updated as necessary. Staffing levels were planned and organised to meet the needs of people. The reliance on agency staff had greatly reduced from previous inspections. Staffing recruitment records were completed and detailed all the necessary checks had been undertaken to ensure people were safe. The administration of medicines practices in the home were not safe as the protocols for take as necessary (PRN) medicines did not include sufficient detail.

People felt staff had the knowledge to care for them effectively. Training was provided for staff to ensure they had the skills to meet people’s needs. Staff received formal supervision, but this was not planned and was delivered on an ad hoc basis. Staff had an awareness of and understood the Mental Capacity Act 2005 and the principles of this had been applied. People had their nutritional needs taken into account and there was a choice at all meal times. Health needs were assessed and the relevant professionals were involved in people’s care provision.

Staff were kind, respectful and caring. People were not formally involved in discussions about their care but felt they were asked about decisions regarding their care. Most care plans were personalised and provided detailed information to guide staff about the support a person needed but some care plans and applicable risk assessments were omitted or lacked sufficient detail to guide staff on how to support people. People had no concerns or complaints about the home and felt able to speak to the manager if they did.

The manager operated an open door policy and welcomed feedback on any aspect of the service. Staff confirmed management were open and approachable.

Quality assurance in the form of auditing took place on a regular basis. Any learning from audits took place and this was reviewed to ensure it brought about effective change.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which correspond to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.