This was an unannounced inspection that took place on 1 November 2018. We returned announced on the 8 November 2018 to complete our inspection.

At our previous inspection on 4 May 2017 we found that people’s risk assessments and the provider’s quality assurance system needed improvement. These were breaches of Regulation 12 Safe care and treatment and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance.

Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions ‘Is the service safe?’ and ‘Is the service well-led’ to at least ‘Good’. At this inspection we found the provider had followed their action plan and was now compliant in these areas.

Hamilton House provides accommodation and personal care for up to 19 adults with mental health needs. There were 15 people living in the home at the time of the inspection.

Hamilton House 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 House has a registered manager. This 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 at Hamilton House. Staff were trained in safeguarding and understood their responsibilities to protect people from harm. Records showed that If concerns arose about a person’s safety staff worked with the local authority and other agencies, where appropriate, to protect the person from harm.

The home had enough staff to support people to stay safe and meet their needs. Staff were available in the home during the day and at night times. If people needed extra support, for example to attend appointments or if they were unwell, extra staff were put on duty.

The provider had acted to reduce the risk of scalding and accidents at the home. Some individual risk assessments still needed to be put in place.

Medicines were well-managed and staff were aware of people’s healthcare needs and knew what to do in an emergency.

People received personalised care that was responsive to their needs. People who were moving towards independent living were supported to acquire the skills they needed to do this. Care plans were regularly reviewed and records showed people making progress towards their goals.

People said the staff was well-trained and knowledgeable. Staff told us they received thorough and varied training. We observed staff supporting people in a skilful and effective manner, providing personal care, company and reassurance where necessary.

People said they were happy with the food served. They said staff encouraged them to eat and drink enough, maintain a healthy diet, and cook for themselves. The home catered for a range of diets. Staff supported people to make healthy food choices where possible.

People could take part in individual and/or group activities if they wanted to. Some of the people using the service had created an attractive garden feature with fish and plants. Other group activities included charity fundraising, exercise on the park, and film nights. Individual activities included health promotion courses, accessing community facilities, and taking part in cultural events.

The premises were spacious and had a choice of lounges and other communal areas. The home was clean and free of clutter. People with reduced mobility had bedrooms on the ground floor to make access easier for them. There was an outside covered smoking area which was popular with people who liked to smoke.

The staff team was established and people and staff had the

The inspection took place on 4 May 2017, and the visit was unannounced.

Hamilton House provides accommodation and personal care for up to 19 adults with mental health needs. There were 15 people living in the home at the time of the inspection.

Hamilton House had 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.

Quality assurance checks undertaken to ensure the quality and safety of service provision were not robust. This meant a number of shortfalls not being identified or addressed. Checks did not cover the assessment and monitoring of the quality of care to ensure care plans and risk assessments were up to date.

There were enough support staff on duty throughout the day to provide people with the support they needed. Support staff knew how to respond to documented concerns so that people were kept safe from harm; however some care plans did not have all the information support staff required to keep people safe. Medicines were managed safely however the storage temperatures were not monitored to ensure they remained potent. Hot water temperatures were not monitored effectively to ensure people were protected from the risk of hot water scalding them.

The provider did not prove they had recruitment procedures in place to ensure staff were of a suitable character to work with people at the home, as we had no access to the staff files. Some staff had received most of the training in the areas considered essential for meeting the needs of people safely and effectively, and some staff had not received this training.

New staff received an induction which included working alongside more experienced staff. This helped them get to know people’s needs and establish a relationship before working with them on a one to one basis. Staff felt there were enough staff to keep people safe and ensure people could attend activities and have planned trips out.

Staff knew people's individual communication skills and abilities and showed concern for people's wellbeing in a caring and meaningful way. Staff worked as a team to ensure people received the appropriate level of observation to keep them and others safe during the day and evening.

Most staff worked within the principles of the Mental Capacity Act 2005 and had a good understanding of their responsibilities in making sure people were supported in accordance with their preferences and wishes. Staff knew people's individual communication skills and abilities and showed concern for people's wellbeing in a caring and meaningful way. Staff were observant of people and responded to their support needs quickly.

Care records were personalised and each file contained information about the person's likes, dislikes, preferences and the people who were important to them. Care plans also included information that enabled the staff to monitor the well-being of people. There were systems in place for staff to share information through having daily records for each person.

Some follow up documentation we requested following the inspection was not received by us in a timely manner, so could not be considered when we wrote our report.

This inspection took place on the 4 March 2016 and was unannounced.

Hamilton House had 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.

The registered manager had reviewed the management of medicines within the service and had made changes to the way in which medicine was brought into Hamilton House, administered and recorded and was supported by a written policy and procedure.

Risk assessments had been carried out where people using the service administered their own medicine. These were regularly reviewed with the person and a member of staff to ensure people safety was promoted. People were encouraged by the service to achieve greater independence in the administration of their medicine as part of their care plan.

People’s medicine administration records had been accurately completed and were consistent with the provider’s policy and procedure. The stock of medicines on the premises which we checked were consistent with the records held by the service, showing people’s medicine was being managed well.

Staff had undertaken training and had had their competency assessed for the management of medicine.

Systems were in place to audit all aspects of the management of medicine which had identified that the policy and procedure was being implemented well.

The Care Quality Commission (CQC) at the next comprehensive inspection will review medicine management to ensure good practice has been sustained.

We carried out a focused inspection of this service on 24 September 2015. The focused inspection was to follow up on the requirements identified at the comprehensive inspection of the service on the 18 and 20 May 2015.

We undertook this focused inspection to check upon the enforcement action we had taken against the provider and whether the provider now met the legal requirements. This report only covers our findings in relation to the requirement and information gathered as part of the inspection. You can read the report from our last comprehensive inspection, by selecting ‘all reports’ link for Hamilton House on our website at www.cqc.org.uk

We will carry out a further focused inspection in the future to follow up on the breach identified at the focused inspection of 24 September 2015 where a breach regarding governance was found.

The provider submitted an action plan following the inspection of September 2015 advising us of the action they would take to address the breach of regulations identified by the end of November 2015.

This inspection took place 17 November 2015 and was unannounced.

The registered manager had reviewed the management of medicines within the service and had made changes to the way in which medicine was brought into Hamilton House, administered and recorded. However this was not supported by a written policy and procedure.

We found people’s records did not contain sufficient information where they had been assessed with regards to the self-management of their medicines. We also found people’s records did not provided sufficient guidance for staff on the administration of medicine that was given as and when required.

The registered manager had liaised with people who used the service to improve practices where people themselves ordered their prescriptions and collected their medicine from the pharmacist.

The registered manager had liaised with a range of health care professionals to review the practice of medicine management within the service; further meetings were planned involving the GP and the supplying pharmacist to bring about further improvements.

We looked at people’s medicine records and found that they had been completed correctly which evidenced that people were administered their medicine as prescribed.

Training for staff in the management of medicine had been scheduled and additional training was being planned. The registered manager had reduced the number of staff involved in the management of medicine to promote safe practices. They told us they planned to put into place checks on staff’s on-going competence once they had accessed training.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Hamilton House had 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.

We carried out an unannounced comprehensive inspection of this service on 18 and 20 May 2015. A breach of legal requirements was found.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now meet legal requirements. This report only covers our findings in relation to those requirements and information gathered as part of the inspection. You can read the report from our last comprehensive inspection, by selecting ‘all reports’ link for Hamilton House on our website at www.cqc.org.uk

This inspection took place on 24 September and was unannounced.

The provider sent us an action plan that stated they had made the required improvements that met the legal requirement. We looked at people’s medicine records and their medicines. We found that systems for the safe recording and administration of medicines were not robust or accurate. This meant there was not a clear audit trail of medicines and therefore the provider could not assure themselves that medicines were being managed safely and that people received safe and effective care and treatment.

Staff responsible for the management and administration of medicine were unable to provide an explanation for the anomalies we identified.

The provider submitted an action plan following the inspection of May 2015 advising us of the action they would take to address the breach of regulations identified. We found that the provider had introduced a process to monitor and ensure medicines were managed safely. However, our findings showed that the management of medicines remained ineffective and that quality of the service had not been monitored by the provider. This showed that the service was not well-led as the appropriate action had not been taken.

We found that the system introduced for the recording of PRN medicine had not been effective. Staff advised us that medicines for use as and when required were now recorded upon receipt and counted. They told us that they would record in the medicine administration record the medicine that had been administered and total the balance remaining. This action had been taken, however the number of medicines on site were not consistent with records we viewed.

Hamilton House had 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.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

As part of the inspection we spoke with four people who used the service, the registered manager and two staff members. We looked at numerous records including people’s care records, staff records, medication records and records in relation to the management of the service.

People we spoke with were positive about the home and the staff team. Our observations showed that people were comfortable and confident in approaching staff and that staff treated people with dignity and respect.

We looked at the records of four people who used the service and found care had been planned and delivered appropriately with regard to people’s health and safety and in accordance with their wishes.

There were appropriate arrangements in place for the obtaining and administration of medication. However, the service did not have appropriate facilities for the safe keeping of medication and in particular for controlled drugs.

Staff demonstrated a good understanding of the needs of people who used the service but had not always been appropriately supported to carry out their roles.

There was an appropriate complaints handling process in place.

Our inspection of 18 October 2012 found limited evidence that the service had an effective quality improvement system and that potential risks to people were being managed effectively. We asked the service to take action to remedy these matters.

We carried out this inspection to check that the service had made improvements to the way it assessed and monitored the quality of service provision. We found that the home had implemented a new system for checks and audits so that risks to people’s health and safety were now being effectively managed. The service had made significant improvements and now had a robust and effective system.

We did not speak with people who used the service at this visit. Please see our previous report for details of what people told us about Hamilton House.

We spoke with five people who used the service. People’s comments were positive and included “it’s the best home I’ve ever been in”, “I can come and go as I please” and “the food is very nice”.

We looked at the support plans and records of five people who used the service. We found people’s needs were assessed and care was planned and delivered in line with their individual plan. We found that support plans were detailed and thorough and provided clear guidance to staff about how people’s care and support should be delivered.

We saw that staff had received training about how to protect vulnerable people from abuse and people using the service could be confident that staff had been screened as to their suitability to work with vulnerable adults.

People who used the service and their representatives were asked for their views about their care and they were acted on. However, we found the quality assurance system the service had in place was chaotic and not always effective.

This inspection took place on 18 May 2015 and was unannounced. We returned on the 20 May 2015 announced.

Hamilton House is registered to provide residential care and support for 19 people with mental health needs. At the time of our inspection there were 16 people using the service. The service is a converted residential property which provides accommodation over three floors. The service is located within a residential area and has an accessible garden to the rear of the property.

At the last inspection of the 7 November 2013 we asked the provider to take action. We asked them to make improvements in the storage of people’s medicines and improvements in the training of staff. We received an action plan from the provider which outlined the action they were going to take which advised us of their plan to be compliant by December 2013. We found that the provider had taken the appropriate action.

Hamilton House had 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.

People told us they felt safe at Hamilton House and staff were trained in safeguarding (protecting people who use care services from abuse) and knew what to do if they were concerned about the welfare of any of the people who used the service. Where people were at risk, staff had the information they needed to help keep them safe.

People said there were enough staff on duty to meet their needs and to enable them to go out with staff support, when needed, to access local services. They said staff were available to talk with them when they experienced an increase in symptoms which affected their mental health.

People who wished to manage their own medicines were supported to do so and assessments of risk had been carried out. We found the system for recording medicine in and out of the service was not robust as their was no clear audit trail to evidence the quantity of medicines received and the quantity of medicines administered or returned unused to the pharmacist. The provider could therefore not be confident that all medicines were being administered as prescribed.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Staff were seen to support people in a confident manner. We saw people were relaxed in the company of staff and talked openly with them about issues affecting their mental and physical health. People told us they attended regular health care appointments with and without staff support. Staff understood people’s health care needs and referred them to health care professionals when necessary.

Staff told us that training had helped them to understand the needs of people, which included their right to make decisions about their day to day lives. People told us they that decisions about their lifestyle choices were supported by staff and were not restricted.

People’s dietary needs were met and people were encouraged to prepare and cook food if they wished to.

People were supported by staff who had developed positive and professional working relationships with them, this gave people who used the service the confidence to speak with staff and talk about issues affecting them. People were able to talk about their lifestyle choices and the impact their decisions had on their well-being and future plans.

People had the opportunity to visit Hamilton House and meet the registered manager, staff and people already living at the service before they moved in. People were involved in their initial assessment and in the developing and review of their plans of care, which included their plans for the future.

People were involved in the day to day running of the service and had the opportunity to undertake cooking, household chores and gardening. People were represented by a ‘spokesperson’ and attended meetings to comment on the service. People were confident that any concerns were responded to by the provider and registered manager.

People were supported and encouraged to be involved in the day to day running of the service and people we spoke with said that Hamilton House was their home. People spoke positively of the registered manager and staff.

The registered manager and staff were committed to meeting the needs of people and improving their sense of well-being by encouraging people to manage their mental health and develop skills to enable them to make informed choices and decisions over their lifestyle choices.

Staff were complimentary about the support they received from the registered manager and regular meetings provided an opportunity for them to develop and influence the service they provided.

The provider had recently introduced audits to check the quality and safety of the service, which included speaking with people who used the service, staff and the reviewing of records. However these had not been sufficiently robust as errors in medicine management had not been identified.