About the service:

Hamilton's Residential Home is a care home that was providing personal care and accommodation to 17 people at the time of the inspection. Most of the people using the service were older people living with dementia.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

People and their relatives told us that they felt safe living at the service. One relative told us, “I feel [my relative] is much safer here, I wouldn’t go on holiday when they were in the other home but here, I haven’t got any worries.” People were protected from risks and their health conditions were monitored to ensure that they remained well and signs of illness. People’s medicines were administered as prescribed. If people needed to see a health and social care professional such as a GP they were supported to do so.

Staff knew people well and people had a say in their care. When people were not able to make decisions for themselves staff followed appropriate guidance to ensure that decisions were made in the person’s best interests. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Where possible people were encouraged to maintain their independence and do things for themselves. People were treated with respect and their privacy was maintained.

There was a pleasant atmosphere at the service. People told us that they were happy, and that staff were kind and caring. People were engaged in activities when we visited such as listening to music, playing instruments and doing puzzles. Relatives were free to visit people when they chose to do so.

The service was clean, and people were kept safe from the risk of infection. The building was suitable for people’s needs although some areas were tired and would benefit from re-decoration. Where people needed support to eat and drink safely this was provided. People were encouraged to eat and drink and where needed their weight and hydration were monitored.

People and their relatives told us that the service was very responsive when they raised issues and acted upon concerns. Staff learnt from incidents and when things went wrong action was taken. This meant that people were protected from concerns re-occurring.

The service was well-led. People and their relatives were positive about the registered manager and the provider and said that they knew them well. The registered manager carried out the appropriate checks to ensure that the quality of the service was maintained.

Staff had the skills, learning and training they needed to support people. Staff were recruited safely and were happy working at the service and felt well supported.

Rating at last inspection:

At the last inspection on 28 March 2018 the service was rated as Requires Improvement.

Why we inspected:

This inspection was a scheduled inspection based on previous rating.

Follow up:

The performance of this service will continue to be monitored and we will visit the service again in the future to check if they are changes to the quality of the service.

This inspection took place on 7 March 2018 and was unannounced.

Hamilton’s Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

There was 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.

At our last inspection in August 2017, the service was rated 'requires improvement' and ‘inadequate’ in the ‘well-led’ domain. This service was placed 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. We received an action plan from the provider, and they told us they would be compliant with all regulations by 31 August 2017.

At this inspection the service demonstrated to us that improvements had been made and it is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures. This is, however, the second time the service has been rated as, ‘requires improvement.’

At our previous inspection medicines had not been managed safely. At this inspection, improvements had been made, however, there was no guidance in place for staff, to inform them when to administer one person’s angina medicine and handwritten medicine administration records had not been double signed to confirm they were accurate. The registered manager rectified these issues during the inspection.

Some people could become distressed, and verbalised suicidal thoughts. There were no window restrictors on upstairs windows, to prevent people from falling from a height. These were purchased on the day of the inspection and we were sent photographs confirming they had been fitted the next day.

The registered manager completed a range of checks and audits but they had not identified the issues we found regarding the safety of the service. Although relatives and staff were asked their views on the service, people and other stakeholders were not formally consulted with.

People’s care plans were now detailed, accurate and fully represented people’s needs. Risks relating to people’s care and support had been assessed and mitigated where possible, and there was clear guidance for staff to follow if people displayed behaviour that challenged. Records were person-centred and contained people’s choices and preferences. Staff had documented what each person wanted to happen at the end of their life and who they wanted present.

Staff documented how much people drank, and totalled this each day to ensure that people were drinking enough. When people lost weight staff took action and consulted with healthcare professionals. Any accidents or incidents were documented and analysed to look for any trends or patterns and ways of preventing them from occurring in the future.

There was clear guidance for staff regarding how to assist people to leave the service in the event of a fire. Regular checks were completed on the water temperatures and equipment to ensure they were safe for people. The service was clean, and people were protected from the spread of infection.

There were enough staff to keep people safe. Throughout the inspection staff spent time w

This inspection took place on 9 August 2017 and was unannounced.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

There was not currently a registered manager in post. The acting manager had applied to the Care Quality Commission (CQC) to become registered and was waiting for their registration interview. A registered manager is a person who has registered with the 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 acting manager led the day-to-day running of the service and was supported by the provider and their representative.

We last inspected this service in February 2017. We found significant shortfalls and the service was rated inadequate and placed into special measures. People were not always receiving their medicines safely. Risks relating to people’s care and support were not always adequately assessed or mitigated. The provider and registered manager had not ensured the premises were safe. The provider and registered manager had failed to report serious safeguarding concerns to the local authority and the Care Quality Commission. Full recruitment checks were not always carried out. Staff had performed a physical restraint on a person and caused a physical injury. People were not always treated with dignity and respect. People did not always receive care and treatment that met their needs or reflected their preferences. CQC had not been notified of important events that had happened within the service. The provider and registered manager had failed to establish and operate systems to assess, monitor and improve the quality and safety of the services provided and failed to maintain accurate and complete records.

We took enforcement action and cancelled the registered manager’s registration. We required the provider to make improvements. This service was placed 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. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that improvements had been made in many areas. However, there were still areas where improvements were required.

Medicines were still not managed safely. Although people’s medicines had been reviewed and changes had been made there was no medicines policy in place, which meant that safe systems and processes were not embedded. We found some pain relief tablets were missing. There was no guidance in place when people were prescribed ‘as and when’ medicines for pain relief or anxiety and their administration was inconsistent.

Records were not always accurate and did not contain the level of detail necessary to mitigate risks. Risk assessments and care plans were not always updated when people’s needs changed. There were still no step by step guidelines in place to ensure staff supported people consistently when they became distressed or displayed behaviours that challenged. The acting manager analysed accidents and incidents, however staff did not always record incidents when people became distressed or aggressive towards staff meaning this analysis was not complete.

Some people experienced urinary tract infections (UTIs) and although staff recorded the amount that people drank on an online system they did not know how to total these to check people had been drinking enough. One person had lost weight and staff had not taken action.

The guidance in p

This inspection was carried out on the 15 and 16 February 2017 and was unannounced. A number of concerns raised by whistle-blowers prompted the inspection. The concerns included people were dehydrated, a lack of staff and an unsafe environment. Initially we were going to carry out a focused inspection to follow up on the concerns with a view to answering one of the key question, is it safe? But whilst at the inspection decided to carry out a full comprehensive inspection and answer all of the five key questions, as further concerns were identified.

In response to the draft report the registered manager and provider sent us comments and additional evidence. This included some medicines records that the provider told us were available on the day of the inspection. Some of these medicines records had been altered and did not match the copies of records we took during the inspection which is concerning.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

The service had a registered manager in post. A registered manager is a person who is 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.

Since our last inspection some staff, including senior staff had left the service. There had been a decline in the standards of care and a decline of the overall rating of the service. There were a large number of documents missing from the service. Evidence of audits and checks completed by the registered manager and the provider were unavailable. Relatives had been asked their views on the service but these results had not been collated or analysed. The registered manager told us that relative meeting minutes were also missing, although relatives told us that they had not attended a recent meeting. Stakeholders and staff had not been asked their views about the service.

The registered manager had not notified the Care Quality Commission of important events that happened in the service, as required by law. They told us they were, ‘unaware’ of this requirement, although this had been an issue brought to the registered manager’s attention at a previous inspection. There had been a high level of staff turnover and a number of new staff were now working at the service. Relatives told us they were aware of some changes, and hoped they did not affect the quality of care their loved ones received. One relative said, “Overall I am happy with the care. There is a high turnover of staff at the moment. It worries me a bit that they have to get to know residents from scratch and residents have to get to know them. That could be unsettling.”

People’s medicines were not managed safely. There were stocks of medicines, not prescribed to anyone currently living at the service that could be given for restlessness, agitation and behaviour that could be challenging. The registered manager said when people first came to the service and were restless and agitated then the medicines may be given following consultation with a doctor. Staff did not always give people their medicines as prescribed. There were multiple instances where staff had handwritten changes on people’s medicines records and there was no evidence these had been authorised by a medical professional. There were no guidelines in place for when staff should administer medicine on an as and when basis.

On two occasions staff had written they had administered people additional medicine they were not prescribed, to help them sleep as they were ‘unsettled’ or ‘agitated.’ We notified the local safeguard

The inspection took place on the 6 July 2016 and was unannounced.

Hamilton’s Residential Home provides personal care and accommodation for up to 17 older people, some of whom may be living with dementia. The service is located on a main road in the surrounding area of Canterbury and is set over two floors. Everyone had their own bedrooms which were well decorated and personalised. At the time of the inspection there were 16 people living at the service.

The registered manager was leading the service on the day of the inspection. 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. The registered manager was supported by a deputy manager and both said they felt supported by the provider.

Staff were not always recruited safely. There were policies and procedures in place for the recruitment of staff however, they were not always being followed. Pre-employment checks were not always completed. The registered manager started to address this during the inspection. We have made a recommendation about this. There was an established staff team some of who had worked at the service for a number of years. There were enough staff on duty to respond to people’s needs. Staff had received training to help them carry out their duties and had regular support ad supervision from the registered manager.

Most medicines were managed safely however improvements were needed to ensure that creams were stored and recorded safely.

Some people were living with dementia and spent time relaxing in the lounge. A door to the lounge regularly banged shut and made people jump and appear anxious. We made a recommendation that the provider seeks advice and takes action to ensure that the environment is suitable for people living with dementia.

People told us they felt safe and looked after in the service. Safeguarding procedures were in place for staff to follow. Staff had completed safeguarding training and knew what action to take if they suspected abuse. The registered manager was confident in dealing with and reporting abuse to outside agencies like the local council safeguarding team.

People had individual care plans that reflected their care needs. People felt staff treated them as individuals and had a good understanding of their needs and how they wanted to be supported. Risks to people were identified and assessed. There was guidance in place for staff on how to care for people effectively and safely and keep risks to a minimum. People or their relatives were involved in writing their care plans. People received care that was responsive to their needs. People pursued their interests and hobbies. There was a range of activities on offer.

Accidents and incidents were recorded and monitored. The service had procedures for responding to emergencies like a loss of electricity or a flood. Safety checks were carried out regularly to ensure the building and equipment was safe.

The registered manager and staff had a good understanding of the Mental Capacity Act 2005 (MCA). When people could not make decisions for themselves the registered manager and staff followed the principles of the MCA and acted in people’s best interests. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS were applied for in accordance with legal guidance.

People were supported to maintain healthy diets and were offered healthy and nutritious meals and regular drinks. People told us they liked the food. People were supported to attend health care appointments and staff worked with local doctors and district nurses to support people’s health needs.

People talked positively about staff referring to them as “carin

Most of the people who used the service had varying levels of dementia which made communication difficult for them. However, people who could, told us that they were happy with the care they received. One person who used the service said "Staff are very good. I am looked after well". A relative we spoke to told us "I am happy with the care my relative gets. Now that there are more staff my relative is more settled and there is a much nicer atmosphere”. Another relative told us, "It’s nice to see people doing things and my relative is really happy”.

We observed how staff interacted with people who used the service and found that people were approached in a respectful manner and saw that staff explained what was going to happen before engaging a person in any care activities.

We were told and we saw that staff meetings had taken place and that staff received regular supervision and training to enable them to fulfil their roles effectively.

We found that there were systems in place for auditing and checking the quality of service and that there was an ongoing improvement programme in place. The views needs and wishes of the people who used the service were included in how the service continued to develop. People’s views and their needs and wishes were taken into consideration in the development and improvement of the service.

People’s care plans and other documentation had recently been reviewed and we found that they were more person centred, up to date and stored correctly.

This was a responsive inspection because people had contacted us with concerns about staffing levels. At the time of our visit the service had a new provider and a new manager who had been in post for two weeks.

Most of the people who used the service had varying levels of dementia which made communication difficult for them. However, people who could, told us that they had no concerns around their care. One person who used the service said "Staff are very good. I have no concerns". A relative we spoke to told us “I am happy with the care my relative gets but I do worry that there are not enough staff on duty”. Another relative told us, “The care is good but staff do not have time to engage with people and there don’t seem to be any activities”.

We observed how staff interacted with people who used the service and found that the care people received was adequate but we were not confident that that there were enough staff on duty to maintain and manage the standard of care.

Peoples care plans and other documentation were not up to date or stored correctly and we found that the provider did not have a process in place to take the needs of people using the service, and the skills and experience of staff into consideration when assessing the numbers of staff required to deliver the service. We found that the provider did not have robust processes in place to ensure that staff were supported to provide care and support that met people's needs in a safe way.There were no systems in place to check the quality of service.

This was an unannounced inspection carried out on 30 June and 01 July 2015.

Hamilton’s Residential Home provides accommodation for up to 17 people who need support with their personal care. The service provides support for older people some of whom live with dementia. The service is a large, converted domestic property in Upstreet. Accommodation is arranged over two floors; the two first floors are not connected and are accessed by separate staircases. The service has 15 single bedrooms and one double room, which two people can choose to share. There were 15 people living at the service at the time of our inspection.

The service is run by the registered manager with a deputy manager. The registered manager was present on both days of our inspection. The registered provider was not present during the inspection. The registered provider is a ‘registered person’ who has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at the service and relatives said that their loved ones were safe. Staff understood the importance of keeping people safe. Risks to people’s safety were identified and managed appropriately. People received their medicines safely and were protected against the risks associated with the unsafe use and management of medicines. Staff knew how to protect people from the risk of abuse.

Recruitment processes were in place to check that staff were of good character. People were supported by sufficient numbers of staff with the right mix of skills, knowledge and experience. There was a training programme in place to make sure staff had the skills and knowledge to carry out their roles. Staff were encouraged and supported to access ongoing professional development by completing vocational qualifications in care for their personal development. Vocational qualifications are work based awards that are achieved through assessment and training. To achieve a vocational qualification, candidates must prove that they have the ability (competence) to carry out their job to the required standard.

People were confident in the support they received from staff. People and their relatives said they thought the staff were trained to meet people’s needs. People were provided with a choice of healthy food and drinks which ensured that their nutritional needs were met. People maintained good physical and mental health because the service worked closely with health and social care professionals including: doctors, podiatrists and community nurses. The registered manager was working closely with the local NHS lead clinical nurse specialist for older people for advice and support.

The registered manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made when this was in their best interests. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager was aware of a recent judicial review which widened and clarified the definition of a deprivation of liberty. Staff knowledge on MCA and DoLS was tested through regular one to one supervision and during staff meetings. DoLS applications to the supervisory body had been made in line with the guidance to ensure the restrictions in place were in people’s best interests.

People and their relatives were happy with the standard of care at the service. People were involved with the planning of their care. People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. Staff were kind, caring and compassionate and knew people well. People were encouraged to stay as independent as possible.

There was a complaints system and people and their relatives knew how to complain. Views from people and their relatives were taken into account and acted on. The registered manager used concerns and complaints as a learning opportunity.

The design and layout of the building met people’s needs and was safe. The atmosphere was calm, happy and relaxed. The risk of social isolation was reduced because staff supported people to keep occupied with a range of meaningful activities which included singing, baking and helping with household chores, such as, washing up.

The registered manager coached and mentored staff through regular one to one supervision. The registered manager and deputy manager worked with the staff each day to maintain oversight of the service. People and their relatives told us that the service was well run. Staff said that the service was well led, had an open culture and that they felt supported in their roles.

There were systems in place to monitor the quality of the service, however, checks and observations on night staff had not been documented. The provider had submitted notifications to CQC in a timely manner and in line with CQC guidelines.

We last inspected Hamilton’s Residential Home in December 2014 when a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 were identified. No breaches of regulations were identified during this inspection. We have made a recommendation that the service finds out more about current best practice on engaging and supporting the specialist needs of people living with dementia.

Since the last inspection in December 2014 the provider and registered manager, with the staff team, had made a number of changes to the service and improvements in the quality of the service delivered. We will check at our next inspection that these changes have been maintained.