This unannounced inspection took place on the 30 and 31 January 2017 and 1 February 2017.

The home is registered to accommodate up to 53 older people who required accommodation and or nursing care. The home is situated close to the town of Buckingham. The registered manager has been in place since November 2015.

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 inspection in January 2016 we asked the provider to take action to make a number of improvements. These included their recruitment practices and medicine practices. We also requested improvements in the application of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards DoLS, and the correct use of pressure relieving equipment, these action have been completed.

During the inspection we spent time with staff who worked well together and who understood the needs of the people they were caring for. They were aware of the values of the service, and from what people told us and our observations we could see they were embedded in their practice. There were sufficient numbers of staff to meet people’s needs. Staff knew what people’s individual needs were, including their preferences. People spoke positively about their relationship with staff and described them as “Empathetic” “Kind” “Calm” and “Nice”. We observed positive interactions between people and staff and it was apparent, people enjoyed spending time with staff.

Staff showed respect for people and preserved their dignity and privacy. People acknowledged this was the case and valued this aspect of their care. For example, people told us they felt comfortable when staff provided personal care.

People felt safe and supported in the home, risk assessments related to care and the environment were in place. Care plans were in place that guided staff to provide appropriate care, these were reviewed on a monthly basis. Staff were able to demonstrate their knowledge and received training in how to identify and report concerns related to abuse.

People’s consent had been obtained where possible and people were supported to have maximum choice and control of their lives. Staff understood the MCA and how this applied to their role. Where people required their liberty to be limited, staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Appropriate applications for DoLS had been made to the local authority.

Medicines were safely administered and stored by trained staff. Records associated to the administration of medicines were up to date and accurate.

Staff were supported through regular supervision and appraisals. Training for staff was provided and kept up to date. New staff completed an induction and the Care Certificate training. Staff spoke positively about the registered manager and the support they received. Staff meetings also took place to encourage feedback from staff and to drive forward improvements to the service.

People told us the food was good but not great. The registered manager and the new chef were in discussions about how the food could be improved. It was still work in progress as the chef had recently taken over the catering from an external catering company.

Staff were aware of people’s nutritional needs and how to support them. Where required charts were completed showing people’s food and fluid intake, this enabled to staff to monitor if people were at risk of malnutrition.

Staff had recorded and monitored the pressure in the pressure relieving mattresses used to alleviate the risk of skin damage. Other health needs were identified and where required, external professionals worked alongside people and

This unannounced inspection took place on the 18, 19 and 20 January 2016. During the last inspection in February 2015 we had concerns about how well staff were trained and able to protect people from abuse. During this inspection we found this had improved. We previously also had concerns about how staff understood and applied their knowledge of the Mental Capacity Act 2005 (MCA) to the care provided. During this inspection we found concerns remained in this area.

Hamilton House Care Home is a residential nursing home for up to 53 older people. The house provides residential accommodation over three floors. Qualified nursing staff and care staff provide care to people.

At the time of the inspection a registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff knew how to identify indicators of abuse and how to report their concerns. The home appeared clean and tidy. Some improvements had been made to the décor of the home with further refurbishment planned in the future.

Documents related to the employment of staff did not show robust and thorough checks on candidate’s employment history had not taken place. We found gaps in their recorded employment histories, there were no documented reasons given for these. This meant the provider could not demonstrate safe recruitment practices were in place. We have made a recommendation about recruitment practices in the home.

We have made a recommendation about the storage and administration of medicines; this was because we saw poor practice in relation to both these areas.

We found insufficient checks and information related to pressure relieving mattresses were in place. This placed people at risk of harm as the correct setting of the mattress was not always clearly documented or adhered to. Staff were not aware of what the correct setting was for each mattress.

During our previous inspection in February 2015 we had concerns related to the staff’s understanding and application of the Mental Capacity Act 2005. Mental Capacity Assessments were not decision specific. We found the concerns remained the same during this inspection.

Staff training was not up to date, but a matrix and plan were in place to improve this area of the service. Records showed staff were supported to carry out their role through supervision, daily meetings and planned appraisals.

Some people were not happy about the quality of the food in the home. The overall opinion seemed to be that it fluctuated between being good some days and poor on other days. The registered manager told us they were working with the kitchen staff to address this. Where people required specialist support with food and fluids this was provided by staff.

People told us the staff were extremely caring and our observations supported this. People told us they felt listened to and respected by staff. They felt involved in their care planning and encouraged to be as independent as possible.

There appeared to be a lack of activities in the home. People told us there were not a lot of activities on offer. Staff told us when they had time they tried to involve people in activities. To address this a newly recruited activity organiser had been appointed.

Care plans and risk assessments were in place for each person. They were kept up to date and reviewed regularly. They included information on people’s preferences and dislikes as well a personal history. This helped staff focus on people as individuals.

Where complaints had been received these had been responded to in line with the provider’s complaints policy. Where possible; learning from complaints took place which helped to improve the service.

The registered m

We spoke with two relatives and four people who lived at the home. We heard many positive remarks, especially about the new manager, the activities co-ordinator, and the variety of the food. Three people told us they liked the activities on offer. They particularly enjoyed them because of the direct input from the activities co-ordinator.

The home was clean, warm and welcoming. We saw people sitting in a conservatory, and in two different sitting rooms with a variety of activities on offer. Their rooms were heavily personalised and comfortable. One person told us "I like my bed; it is much nicer than the one I had at home." Relatives told us the manager was friendly and approachable, and "She really keeps an eye on what is happening."

We heard that the food was delicious, and usually well-presented. We saw breakfast being prepared very early in the morning. Some items were stored in a hot trolley for a long time before breakfast was served. We also noted that some food stored in the refrigerator, and in the dry food store, was not labelled. The kitchen staff told us they had just run out of labels and had requested more be delivered that day. We observed lunch being home-made, and heard appreciative comments about the cheese and tomato quiche.

The manager recorded a wide range of quality assurance checks on a regular basis. These included staff, relative and resident meetings.

The few complaints we saw had been dealt with quickly and appropriately.

We spoke with seven people who used the service and four relatives who were visiting family members on the day of our visit.

People said they were happy with the care and support they were receiving. One person said, “I am well looked after.” A second person said, “I am able to make choices”. “I choose what clothes I wish to wear and what to eat.”

Relatives said they were very happy with the care and support their family member was receiving. One relative said, “Staff are excellent. They keep me informed of my relative’s care.” A second relative said, “I can’t fault the care that staff provide. It is very good.”

People described the way staff spoke to them as “respectful and polite.” One person said, “I love living here. I feel safe.”

People said there were sufficient staff employed. People described staff as “excellent, very good, approachable and kind.”

People told us they were aware of how to make a complaint. People said when concerns had been raised to the manager they were addressed appropriately.

We found people’s needs were assessed and their care was provided in line with their individual care plan. People were protected against the risk of abuse. People’s medicines were safely administered. There were sufficient staff employed to meet people’s needs. There was an effective system in place to regularly assess and monitor the quality of the care people were receiving. Complaints were responded to appropriately.

This inspection took place on the 18 and 19 February 2015. At the last inspection on 8 April 2014 we found there to be inadequate staffing levels. We asked the provider to take action to make improvements to the staffing levels in the home and this had been done.

At the time of this inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Hamilton house provides residential and nursing care for up to 53 older people. At the time of the inspection there were 42 people living in the home.

People told us they were happy living in the home; they felt well cared for and safe.

We found some areas of concern in the home where cleaning was not satisfactory and presented a risk to people’s health. We have made a recommendation about infection control. Some rooms needed re decoration and trailing wires placed people and staff at risk of trips or falls. We have made a recommendation about the health and safety of the premises. The registered manager could not demonstrate knowledge of the Mental Capacity Act 2005 or the procedure for reporting and responding to safeguarding concerns. The provider did not appear to be aware of these areas of concern even though audits had been completed. We have made a recommendation about the quality auditing of the service.

Staff cared for people in a respectful and gentle way. They were knowledgeable about people’s needs and understood how to support people in a way that made them feel comfortable and protected their dignity. People and their relatives were able to speak to the registered manager and staff and raise any concerns or complaints. Records showed these were dealt with appropriately and in a timely way. Activities were provided most days to ensure people’s social needs were met. People told us they enjoyed the activities.

People’s health was monitored and where appropriate referrals were made to external professionals such as physiotherapists. People told us staff responded quickly to changes in their health needs and when they became unwell the staff took the appropriate action to ensure where possible their health was maintained.

People enjoyed the food provided at the home. Additional snacks were available and people could choose what they wanted to eat. Where people had difficulties eating, staff supported them.

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.