Archived: The Hamiltons Care Home

This comprehensive inspection took place on the 09 and 10 January 2018. The first day was unannounced. This meant the provider did not know we would be visiting the home on this day. The second day was announced.

The Hamiltons 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; both were looked at during this inspection.

The Hamiltons provides personal care for up to 18 people. The service has bedrooms and communal rooms including bathrooms to the ground floor and to the second floor further bedrooms and bathrooms are situated. It has a passenger lift between the floors and a large stair case at each side of the building for easy access between both floors.

As part of the homes registration conditions it is required to have a registered manager employed to oversee the day to day running of the service. A registered manager has been in post at the service since February 2017.

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 the last comprehensive inspection on 01 and 02 December 2016 we found one continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment. We recognised that although medicines practice had significantly improved since our previous inspection in April 2016 the service was still required to improve on areas such as missing signatures on medicine records and a lack of omission codes being used for medicines which were prescribed as, ‘when necessary’ (PRN).

At this inspection we found the service was now compliant in this area. Medicines records were now completed appropriately including PRN, as required and staff were now using the correct coding system. Medicines audits were robust and identified any errors. Medicines were kept secure and staff were appropriately trained to administer medicines in a competent way.

Safeguarding policies and procedures were in place to ensure people, staff and visitors were aware how to raise concerns if needed and what constitutes abusive practice. Staff received training in this area and a record of safeguarding referrals was kept securely.

Risk assessments were in place in people’s files to recognise individual risk taking and also environmental risk assessments were completed for both internal and external areas. Appropriate checks were done by registered external tradespersons on areas such as gas appliances, fire equipment, electrical appliances, hoists and lifts.

Business continuity plans were in place to offer information and guidance in the case of adverse weather or any other unforeseen circumstances which could affect the day to day running of the service. People had personal evacuation plans and fire audits were completed by both external agencies and internally by the maintenance person.

The service had recently undergone a decorating schedule, mainly in the communal areas which made the environment brighter. We observed no malodour around the building during the inspection.

During the inspection the service had an outbreak of upper respiratory infection which meant a number of people using the service were required to be cared for in their bedrooms. The service dealt with this well and contacted the relevant authorities to seek advice and guidance.

People had care files which contained person centred information. Each care file was written in a way which reflected the individual and only contained documents relevant to the person. People’s human rights and diverse needs were reflected within each plan and we received positive feedback during the inspection which evidenced people were being treated fairly and in line with their personal preferences.

The home was working within the requirements of the Mental Capacity Act (MCA). Deprivation of Liberty Safeguards, (DoLS) applications were made where people were deemed to lack capacity to make their own choices and decisions about their care.

Staff interacted and engaged well with people. Staff were caring, respectful and understanding in their approach and treated people as individuals. They promoted privacy and dignity and supported people to maintain control over their lives. People’s opinions were routinely sought and acted upon by means of questionnaires and residents meetings. This enabled people to provide influence to the service they received.

Recruitment processes were robust and designed to protect people using the service by ensuring appropriate steps were taken to verify a new employee’s character and fitness to work.

The service had a sufficient number of staff to support the operation of the service and provide people with safe and personalised care. People told us they never felt rushed and staff were responsive to their needs.

Staff received training appropriate to their roles and prior to becoming an established member of staff they were subject to a period of induction, training and supervision.

Positive feedback was received from people who used the service and staff about the management structure. People told us they were able to ask for assistance from the registered manager when required and people also informed the registered manager was present throughout the day in the communal areas. Staff also said they felt well supported and they could approach management with any concerns.

We last visited The Hamiltons Care Home 28 April 2016. At that time eight breaches of legal requirements were found. These related to a failure to send appropriate notifications of abuse to the Commission. We also found further systems and processes had not been operated effectively to prevent the abuse of people using the service. The service did not demonstrate that they had provided care and treatment appropriate to meet people’s needs and reflect their preferences and had failed to assess, monitor and improve the quality and safety of people using the service. The service did not always treat people with respect and had failed to act on feedback from relevant people. The service had failed to ensure the safe management of medicines and had not securely maintained confidential records. The service had failed to establish and operate effective recruitment procedures and had not ensured sufficient numbers of suitably qualified staff were employed. As a result of this the service was rated inadequate.

Following the inspection, the provider wrote to us to identify what actions they would take to meet legal requirements.

During this inspection we found significant improvements had been made to meet legal requirements. However we found the service to be in continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment. This was in relation to medicines management. You can see what action we told the provider to take at the back of the full version of this report.

The Hamiltons Care Home provides accommodation and personal care for up to 18 people. The home is situated close to Atherton town centre and other local amenities. All rooms at the home are for one person but there are two adjoining rooms that can be made into a double room if this was required. Six rooms have en suite facilities and all rooms have a hand wash basin. Toilets and bathrooms are in close proximity to bedrooms and communal areas. There is a small car park at the front of the home.

At time of inspection the service had been without a registered manager for 371 days. However there was a manager in post who had submitted an application to the Care Quality Commission to be registered as the manager for 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 2008 and associated Regulations about how the service is run.

Medicines were stored in a secure place and there were systems in place to monitor aspects of medicine management practices on an on-going basis. Staff had received training in safe administration of medicines and daily audits were completed. However, we noted a number of medicines administration records (MARs) were still missing signatures. In addition to this in some instances we saw the lack of omission codes being used for medicines which had been refused or not required

People told us they considered themselves safe whilst living at The Hamiltons Care Home. They also indicated that the care they received was delivered in a professional and caring way and that staff had the correct skills to undertake their role effectively.

People were now provided with personalised care and support based on their individual needs and requirements. Care files contained person centred assessments and support plans to enable the development of the care planning process and support the delivery of care. Effective systems were implemented to maintain independence, by providing a detailed plan covering essential information staff needed to follow. This ensured clear information about people's needs wishes, feelings and health conditions were kept under regular review.

Staff interacted in a positive way with people. Their demeanour was that of a caring, respectful and understanding nature. The promotion of people's dignity and rights were supported which ensured people maintained control over their lives. People were given information about their care and the service to help them make informed decisions. Their opinions were now routinely sought and acted upon by means of questionnaires and one to one meetings and residents meetings were planned for the new year. This enabled them to influence the service they received. Comments were received from people during the inspection which supported these observations.

We found people were protected from risk without compromising their independence. Processes were in place to ensure the safety of people using the service, staff and visitors by means of environmental and individual risk assessments.

Clear safeguarding policies and procedures were in place at the service. These provided staff with guidance and training in recognising the signs of abuse and helped to ensure the staff team were fully aware of action they needed to take should they be concerned about a person’s welfare. Staff and the manager displayed appropriate knowledge about how to respond to and ensure any safeguarding issues had been notified to the relevant authorities and the Commission.

Fire risk procedures were in place and detailed environmental fire risk assessments were followed. People using the service had personal evacuation plans (PEEP) in place and staff we spoke with understood the processes to follow in the case of an emergency. The service also had contingency plans in place in the event of failure to utility services or equipment.

The service operated with three staff members on each shift during the day and two staff during the night. We saw on some occasions that only two members of staff were rostered for shifts during the day. The manager told us this was due to a high number of staff sickness and in most cases these shifts would be covered by additional staff. Comments from people supported that there were enough staff to safely meet their needs and people told us they never felt rushed with their routine. Staff informed us that although it could be busy when working with one member of staff down this was not a frequent occurrence and this was never to a dangerous level. The manager told us she had begun to recruit additional staff to alleviate this issue. This will be monitored at the next inspection.

The provider had ensured a robust recruitment system had been implemented. Appropriate steps were now taken to verify new employee's character and fitness to work. Following successful appointment to the role the provider ensured a thorough induction plan was carried out which ensured staff were equipped with the correct skills and knowledge to effectively support people in an informed, confident and self-assured manner. We noted the provider also offered a variety of training to its staff which ensured the staff team were skilled and experienced in safely and effectively supporting the people using the service.

Mealtimes were relaxed and people told us they did not feel rushed. People told us they were able to request a different meal should they not like the menu choice. Refreshments were offered throughout the day and people were not limited to specific times or amounts of fluids taken. Referrals had been made to health professionals when appropriate and instructions were followed in cases where people had known dietary requirements.

Staff displayed an awareness of the Mental Capacity Act 2005 and had completed appropriate training. Referrals had been submitted to the local authority by the manager when appropriate and conditions were adhered to.

All people spoken with including relatives and staff were very complimentary about the new management structure. People described the manager as helpful and professional and any questions/ issues would be dealt with effectively and professionally. Each person we spoke with told us they felt the service had improved significantly whilst under the new manager.

It was evident that the ethos of the service was now built on care and trust. The manager was very passionate about her role and had brought about a considerable amount of change to the service to ensure compliance with regulations. Although some of these processes were still in their infancy it was evident that these processes had enabled a safer and more person centred way of working. This was also reflected in comments from people.

The Hamiltons Care Home is registered to provide personal care and support for a maximum of 18 people. At the time of the inspection, there were 17 people living at the home and one person was in hospital. The home is situated close to Atherton town centre and other local amenities. All rooms at the home were for one person but there were two adjoining rooms that could be made into a double room if this was required. Six rooms had en-suite facilities and all rooms had a hand wash basin. Toilets and bathrooms were in close proximity to bedrooms and communal areas. There is a small car park at the front of the home.

At the last inspection on 12 January 2016 the service was given an overall rating of requires improvement. At that time we found the provider had not made the required improvements in relation to three of the regulations that were outstanding breaches which were identified at the previous inspection on 23 February 2015 relating to pre-employment checks for staff; care planning; training and supervision. At the inspection on 12 January 2016, we also found additional breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to systems and process in place to ensure the service was not inappropriately restricting people of their liberty; display of performance ratings; having adequate systems in place to monitor and assess the quality of service provision.

At this inspection on 28 April 2016 we found the provider had not made the required improvements in relation to the breaches identified at the inspection on 12 January 2016 regarding safeguarding, training and mitigating risk. We found 11 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of dignity and respect, safe care and treatment, safeguarding, staffing, person-centred care, good governance and fit and proper persons employed. You can see what action we have asked the provider to take at the back of the full version of this report. We also found one breach of the Care Quality Commission (Registration) Regulations 2009 in relation to the notification of other incidents. You can see what action we told the provider to make at the back of the full version of this report.

People we spoke with who lived at the Hamiltons told us they felt safe living at the home, but one relative said that they felt there were insufficient numbers of staff on duty and they were looking for an alternative home for [their relative].

Appropriate safeguarding procedures were not in place to safeguard people from abuse and the home had failed report five safeguarding incidents to both CQC and the local authority.

There was no formal dependency tool to establish how many staff were needed to support people safely and staff told us they felt that staffing levels were too low. We also observed there were insufficient staff to care for people safely.

People who lived at the Hamiltons sat unstimulated in the lounge area throughout the inspection and with the last recorded activities taking place on 19 April.

During the inspection we observed these people weren’t closely monitored by staff, in accordance with their needs, which could place these people at risk.

Medicines were not managed in a safe way, including four separate instances where medication had been signed as being administered, when they hadn’t; an unlocked medicines room door; gaps in the recording of medicines fridge temperatures; two controlled drugs which could not be accounted for in the controlled book; some ‘over-stock’ controlled drugs were being stored in an unsuitable cabinet.

Bathing and showering records had not been completed since early April 2016. This had also been raised as a concern in the whistleblowing information we received prior to the date of the inspection.

Whilst looking at the accident and incident records, we noted four falls which had occurred in the month of April 2016. As a result of these falls, the recommended action was for there to be a staff presence at all times in order to ensure the safety of these people. However during the inspection we observed these people weren’t closely monitored by staff which could place these people at risk.

At our previous two inspections in February 2015 and January 2016, we had concerns with how the home recruited new staff. During this inspection we still had concerns about how the home recruited staff. In one of the staff personnel files we looked at, we couldn’t see any evidence of references being sought from previous employers. In two other files we could not see evidence of interviews being conducted and what the responses from applicants had been to the questions asked.

We found the service did not always mitigate risks presented to people living at home. We noted people had environmental risk assessments in their care plans. These risk assessments contained control measures such as all staff being trained in fire safety and the use of an extinguisher; however we found staff had not received this training when looking at training records.

All fire exits in the home also needed to be clear from obstacles, however we observed one exit to be blocked with arm chairs and walking frames in the conservatory.

We noted one person had fallen from their bed during the night. The control measures to be implemented included regular checks during the night. We asked to see evidence that these checks had been undertaken, however the service as unable to produce these.

The décor throughout the home was in need of refurbishment and we saw that a handyman was employed by the service and was undertaking a program of redecoration.

There was no menu displayed in the dining room and everybody had the same meal. We witnessed several poor interactions between staff and people who required support during the lunch time meal, as staff got up from the table on several occasions without explaining where they were going. One of the people affected by this was registered blind.

We saw there were some adaptions to the environment, which included pictorial signs on some doors, such as bathrooms, which would assist people living with a dementia to orientate around the home.

At our last inspection on 12 January 2016 we were concerned about how the service worked within the principles of the MCA and DoLS. We saw there had been eight applications for DoLS made to the supervisory body prior to the date of the inspection. The manager said seven of these had not yet been authorized. However there was no evidence of capacity assessments being undertaken, where appropriate.

At our last inspection on 12 January 2016, we had concerns regarding staff training and competencies. At this inspection, there was no staff supervision schedule in place. Two staff members told us they had not received any form of regular supervision which they found demoralizing and one staff member told us they had never seen the manager since they commenced in post several months prior to the date of the inspection.

There was no evidence in staff files that the training needs of new staff had been considered. It was not clear that there was any programme of training or support in place to ensure that the requirements of the care certificate were being met.

The people we spoke with told us they liked living at the home and staff we spoke with demonstrated a good understanding of the needs of people living at The Hamiltons. We saw that staff knocked on people’s bedroom doors and waited for a reply before entering and they were able to tell us about how they helped people to maintain their independence.

People said they felt treated with dignity and respect. However, we observed one instance where a staff member placed a medicine into a persons’ mouth without first asking their permission or explaining what was happening, and another instance where a staff member placed a tabard on one person without asking them first.

People’s care files contained information about how staff could effectively communicate with people, for example through non-verbal communication. Care files also contained end of life care plans, which documented people’s wishes at this stage of life where they had been open to discussing this.

We looked at the bathing and showering records for all the other people who lived at the home and found extensive gaps in all the records. Although most people’s records indicated they had had a ‘wash’ it was not clear how thorough this was and records indicated that baths and showers were not being carried out frequently for all people who used the service.

Staff told us they struggled to interact and socialise with people due to poor staffing levels at the home and this was evident through our observations.

At our last inspection we raised concerns about pre-admission assessments either not being completed, or lacking in detail. We looked at any pre-admission assessments undertaken since the last inspection. We saw these were completed with good detail.

During the inspection we looked at four care plans and found they were not always reviewed at regular intervals and this was a concern we had raised out our previous inspection.

The manager told us that the service had not received any recent complaints. We could not find a copy of the complaints policy on display but people who used the service and their relatives told us they knew how to complain.

At the time of our inspection, there was a manager in post, but they weren’t yet registered with CQC. 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.

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The Hamiltons Care Home provides accommodation and personal care for up to 18 people. At the time of our visit 18 people were living at the home. The Hamiltons is situated close to Atherton town centre and other local amenities. Six rooms have en-suite facilities and all rooms have a hand wash basin. There is a small car park at the front of the home.

We last inspected The Hamiltons on 23 February 2015. At that time we rated the home as ‘requires improvement’ and identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the provider had not made the required improvements in relation to three of the regulations and there were on-going breaches relating to pre-employment checks of staff; care planning and training and supervision. We found additional breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to: Systems and processes in place to ensure the service was not inappropriately restricting people’s liberty; display of performance ratings; and having adequate systems in place to monitor and assess the quality and safety of the service. You can see what action we told the provider to take at the end of this report. We are considering our options in relation to enforcement for some of the breaches of legislation and will report further once any action has been completed.

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 the time of our inspection there was not a registered manager in post. However, the acting manager was in the process of registering with CQC.

The acting manager discussed plans they had to improve the service with us, and staff told us they felt positive changes had been made by the acting manager. The acting manager had been in post for approximately three months at the time of the inspection. We raised concerns that the provider had not ensured areas we had identified for improvement such as keeping accurate records of training had not been improved since our last visit.

We saw some evidence that staff had undertaken training, but this was inconsistent and there was no clear overview of what training staff had completed. Staff had not received recent supervision, which meant the provider could not ensure they were competent and receiving the support they required.

The completion of care plans was carried out to a variable standard. We found two care plans did not have up to date risk assessments in relation to areas such as malnutrition and mobility. Two care files also did not contain full care plans despite the people these related to having lived at the home for some time. We also found some pre-admission assessments were lacking in detail or missing from the care files. This meant the provider could not demonstrate they had carried out adequate assessment of people’s needs and preferences. It also meant there was a risk that people would not be receiving care in accordance with their needs.

People said they liked the food provided and told us they were able to request an alternative should they not like the choices on the menu. People and their relatives we spoke with told us staff at the home were caring and approachable. We saw that people were treated with respect and given the time they required without being rushed. Staff demonstrated a good awareness about steps to take to help ensure people’s privacy and dignity.

Staff had a reasonable understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). However, none of the staff at the home were aware of who, if anyone had an authorised DoLS in place and there was no clear record kept of this. This meant there was a risk that staff would not be acting in accordance with any authorised DoLS, or that they may be restricting people’s liberty without lawful authority.

There was a lack of systems in place to monitor the quality and safety of the service. The gas safety check was one month overdue and this was not picked up until pointed out by the inspection team. There was no monitoring or analysis of accidents or incidents in the home and no overview of care plan audits carried out. The service could only show us one audit of medicines carried out, which should have been completed monthly.

We were told the provider regularly visited the home and carried out an audit. However, the acting manager said they did not receive any copy of an audit and we did not see any evidence of this. There were no current systems in place to effectively monitor the training and support staff were receiving.

The provider had introduced a human resources audit to help ensure the required checks and documentation were in place prior to any new staff member starting employment. However, two of the staff personnel files we looked at had gaps in the records of employment history and there was no written confirmation as to the reasons for this as is required.

The home was not displaying its performance rating physically at the home nor online as is a requirement.

We looked at the systems in place to ensure that people were protected from the risks of abuse. We found that there were appropriate procedures in place and that staff were aware of their responsibilities to protect vulnerable adults.

We found that there was an effective recruitment procedure in place to ensure that appropriate people were recruited to work in the home. We also found that there sufficient numbers of suitably qualified staff on duty to ensure that people were safe.

We checked the systems in place for monitoring the quality of care provided at the home and found that an effective system was in place. The people we spoke with could not think of anything that needed to be changed or improved.