Archived: Hamilton House & Mews

This inspection took place on 31 July and 21 August 2015 and was unannounced.

Hamilton House is a nursing home that provides care, support and accommodation for up to 39 people with mental health needs. At the time of our inspection there were 28 people living in the home.

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

The registered manager had been absent from the service since the beginning of July 2015 and the deputy manager ceased their role with the organisation on 31 July 2015. The provider informed us that a named nurse would be responsible for managing the service with effect from 6 July 2015.

Our previous inspection of November 2014 identified a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (which corresponds with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). We identified concerns that people’s medicines were not managed safely.

During our inspection on 31 July we acknowledged that, although improvements had been made, there were some areas that still required improvement. This meant that there was a continuing breach of Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were still some record-keeping discrepancies that had not been identified by the internal audit and there was a lack of records showing further attempts to administer people their medicines, where they had been refused or not administered at the times prescribed.

Our previous inspection of November 2014 identified a breach of Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (which corresponds with Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). We identified concerns that the registered person did not operate an effective recruitment procedure to ensure that only suitable people were employed at the service.

During our inspection on 31 July and 21 August we found that improvements were still required in this area. This meant that there was a continuing breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

No recruitment records or personnel files were available on the premises for three new members of staff.

Our previous inspection of November 2014 identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (which corresponds with Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). We identified concerns that proper steps were not being taken to ensure the dignity and respect of people in the home.

During this inspection we found that there were some areas that still required improvement. This meant that there was a continuing breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us that most of the staff were caring and generally treated them with kindness and respect. Interactions between some staff and people living in the home were particularly warm, reassuring and considerate. However, People were not always treated with respect and people weren’t always able enhance or maintain their independence because there were not always enough staff to provide people with the individual support they required.

Our previous inspection of November 2014 identified a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (which corresponds with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). We identified concerns that the registered person did not have an effective system in place to monitor and assess the quality of service provided to people. Audits and quality assurance monitoring were not completed or addressed to identify, assess and manage risks relating to the health and welfare of people in the home.

During this inspection we found that improvements were still required. This meant that there was a continuing breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider’s systems for monitoring, assessing and improving the service were ineffective and appropriate measures were not being taken to consistently identify and mitigate risks for people living and working in the home.

People told us that they felt safe living at the home and that they would talk with staff or the nurse if they had any concerns. Staff told us they understood what constituted abuse and were confident in reporting any concerns. However, low staffing levels and the poor quality of staff training compromised staff’s ability to consistently ensure people were kept safe from avoidable harm.

Risks to people’s safety were assessed but records were not all up to date or fully completed. The management of some of the risks identified was not always effective because actions to reduce, remove or improve the risks to people were not always taken or recorded appropriately.

There were not enough staff to ensure people were consistently kept safe and have their needs fully met. The shortfalls included housekeeping staff as well as care staff. This meant that some people did not receive the specific one-to-one support that they were funded for and other people were not being supported sufficiently in line with their identified needs.

Staff did not consistently receive effective support and were not enabled to access appropriate training that would ensure they had the relevant skills and knowledge to be able to meet people’s needs and provide care and support safely and effectively.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find.

The service was not meeting the requirements of MCA and DoLS because the provider had not acted on the requirements of the safeguards to ensure that people were protected. Staff members did not understand the MCA well and best interests decisions were not always documented appropriately. The service was also not following correct procedures when medicines need to be given to people without their knowing (covertly).

People told us that they had enough to eat and drink, although we were concerned about people’s quality and choice regarding some of the food. There were a number of gaps in the records for people who needed their food and drink intake and weights to be monitored, to ensure they remained healthy.

People had access to various healthcare professionals, according to their needs and regular visits to the home were also made by external practitioners, such as the chiropodist and a diabetes advisor.

Due to the lack of sufficient numbers of staff and effective deployment, people were not consistently able to access the local community as they wished. This was sometimes because there were no drivers on duty for the home’s mini-bus or because staffing levels were not sufficient to enable a driver to take people out. Allocated one-to-one time for people and organised activities that were advertised within the home, were also not consistently being provided because there were regularly not enough staff on duty.

People told us that they spoke to staff or told the nurse or the deputy manager if they had any problems or wanted to make a complaint. However, staff were not completely sure how complaints were handled.

There was a lack of oversight from the provider with regard to the overall running of the service. The provider also did not demonstrate accountability or effective leadership because they did not ensure that appropriate action was being taken to improve shortfalls, where issues had been identified.

Our findings during our inspection of 31 July and 21 August 2015 showed that the provider had failed to “…meet every regulation for each regulated activity they provide…”, as required under the HSCA 2008 (Regulated Activities) Regulations 2014 (Part 3).

We found that the provider was in breach of eight regulations. You can see the action we have told the provider to take at the back of the full version of the report.

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.

We carried out an unannounced comprehensive inspection of this service on 8 May 2014. Breaches of legal requirements were found. As a result we undertook a focused inspection on 19 September 2014 to follow up on whether action had been taken to deal with three of the six breaches we found. The remaining breaches will be followed up at a later date.

Comprehensive Inspection of 8 May 2014 

Hamilton House and Mews is registered with the Care Quality Commission (CQC) as a care home. Hamilton House and Mews are two separate buildings in the same grounds and managed by the same registered manager. They provide residential care for up to 24 adults in the House and 14 in the Mews, all with mental health needs. On the day of inspection there were 19 people in the house and six in the Mews.

The home had a registered manager. A registered manager is a person who has registered with CQC to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The DoLS are a code of practice to supplement the main Mental Capacity Act 2005 Code of Practice.

We looked at whether the home was applying the DoLS appropriately. These safeguards protect the rights of adults using services by ensuring that if there were restrictions on their freedom and liberty these would be assessed by professionals who were trained to check whether the restriction was needed. Whilst no one at the home required these safeguards at the time of our inspection, we found there were proper policies and procedures in place to protect people who could not make decisions for themselves. There was evidence that staff had received training but two out of six staff were unclear about how the principles of the MCA should be taken into consideration within their day to day work. Four of the staff spoken with could not demonstrate a good understanding of the Deprivation of Liberty Safeguards (DoLS) but the provider has stated staff would be supported by the management team to ensure people were not deprived of their liberty.  

The service did not always follow current and relevant professional guidance about the management of medicines, which meant people were at risk.

There were enough staff on duty to provide the care and support needs for people in the home. Five out of seven people told us that staff lacked compassion and did not treat them with respect.

People’s welfare and safety was at risk because the individualised risk assessments had not been updated.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Focused Inspection of 19 September 2014 

Following our inspection of 8 May 2014 we issued a warning notice to the provider and registered manager of the home in respect of a breach relating to Regulation 13 of the Health and Social Care Act (Regulated Activities) Regulation 2010, the Management of medicines. The main purpose of this focused inspection was to establish whether appropriate action had been taken in relation to this breach.

We found that the provider had taken adequate action to improve the way people's medicines were managed, however a few minor shortfalls in the arrangements required addressing. The provider was no longer in breach of this regulation. 

During this inspection we also followed up on progress made in respect of a breach of Regulation 11, Safeguarding people who use services from abuse where we had issued a compliance action.

Staff were undergoing further training and updated procedures were in place to support them. Staff we spoke with were knowledgeable. We spoke with people living in the home and they told us the staff treated them well. We were satisfied that the provider had taken appropriate action and that this regulation was no longer being breached.

In addition we followed up progress made in respect of a breach of Regulation 10, Assessing and monitoring the quality of service provision where we had issued a compliance action.

Although progress had been made since the May 2014 inspection, we still had concerns about the effectiveness of systems in place to assess and monitor the quality of the service people received. Substantial progress had been made on reviewing people’s individual risk assessments, nutritional assessments and medication auditing. Other areas that still required improvement included the monitoring of food and fluid charts, obtaining the views of people living in the home and staff. However, our main concern was the lack of robustness of the audits undertaken in relation to health and safety and infection control. These had not picked up issues requiring attention that we had identified during our inspection. The provider was still in breach of this regulation.