Hamilton Nursing 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. The home can accommodate up to 38 people in an adapted, detached house; 36 people were living there at the time of our visit.

At the last inspection, the service was rated Good.

At this inspection we found the service remained Good, with one key Question, Responsive improving to Outstanding.

People had access to a wide range of group and individual activities and events they could choose to participate in, which were tailored to meet their specific social needs and interests. This enabled people to live an active and fulfilling life.

People received person-centred care which was responsive to their specific needs and wishes. Each person had an up to date, personalised care plan, which set out how their care and support needs should be met by staff. Assessments were regularly undertaken to review people's needs and any changes in the support they required.

People who preferred or needed to stay in their bedroom were also protected from social isolation. People regularly participated in outings and activities in the local community. The service also had strong links with local community groups and institutions.

When people were nearing the end of their life, they received compassionate and supportive care.

Staff were aware of people's communication methods and provided them with any support they required to communicate in order to ensure their wishes were identified and they were enabled to make informed decisions and choices about the care and support they received.

The service had appropriate arrangements in place for dealing with people's complaints if they were unhappy with any aspect of the support provided at the home. People and their relatives said they were confident any concerns they might have about the home would be appropriately dealt with by the managers.

People were kept safe at the home, cared for by staff that were appropriately recruited and knew how to highlight any potential safeguarding concerns. Risks to people were clearly identified, and ongoing action taken to ensure that risks were managed well. People’s medicines were managed safely and the provider ensured that incidents and accidents were fully investigated. The home was well kept and hygienic.

Staff were well supported through training, supervision and appraisal. Staff worked effectively together to ensure people’s needs were communicated and supported them to access healthcare professionals when they needed them. People enjoyed the meals available to them and were appropriately supported with eating and drinking. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

The home was dementia friendly and met the needs of the people living there. Staff could demonstrate how well they knew people and people and their relatives were extremely positive about the care provided. People were treated with privacy and dignity and supported to be as independent as possible whilst any diverse or cultural needs were respected. People’s end of life wishes was sensitively discussed and recorded.

People were supported to maintain relationships with their relatives, and the provider was innovative in seeking people's views to ensure they had access to a wide range of activities. Staff had an excellent understanding of how to respond to people’s needs. Any complaints were dealt with appropriately.

The service had a robust management structure in place, and quality assurance systems were effective in driving improvements across the home. Regular feedback was sought from people and their relatives to ensure they were involved in the development of the

This inspection took place on 8 December 2015 and was unannounced. At our previous inspection on 8 January 2014 the service was meeting the regulations inspection.

Hamilton Nursing Home provides nursing care and support to up to 28 older people, some of whom have dementia. At the time of our inspection 26 people were using the service.

The service had a registered manager in place. 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 were provided with care and support that was tailored to their needs. Staff assessed people’s personal care and nursing needs, and developed care plans about how those needs should be met. Staff were knowledgeable about people’s needs and supported them in line with their care plans.

Staff were aware of people’s likes, interests and routines. Staff liaised with people’s relatives to obtain information about their life story including previous occupations and significant events. This information was used to help staff to provide personalised care.

A wide range of activities were provided at the service, so that all people could take part in activities. This included using the Namaste programme which stimulated people’s senses, and did not rely on people being able to communicate verbally or be physically active.

Staff were aware of people’s communication needs, and communicated with people in a way people understood. This included the use of hand gestures and body language. Staff offered people choice about their day to day care and respected their decisions.

Staff were aware of the principles of the Mental Capacity Act (MCA) 2005. Staff arranged for MCA assessments to be undertaken to establish if people had the capacity to consent to care decisions. ‘Best interests’ meetings were held for people that did not have the capacity to consent. The registered manager had organised for people to be assessed as to whether they required a Deprivation of Liberty Safeguard (DoLS) to keep them safe. For those that had a DoLS in place, staff adhered to the conditions stipulated. DoLS is a way of making sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

Staff were aware of the risks to people’s safety, and supported them to manage those risks. This included risks associated with developing pressure ulcers, falling and malnutrition. Staff supported people with their nutritional needs, and liaised with other healthcare professionals to support people with their healthcare needs. There were safe medicines management processes in place and staff ensured people received their medicines as prescribed.

Staff were aware of their duties in regards to safeguarding people and reporting concerns, incidents and accidents. Incidents were reviewed and action was taken to minimise the risk to people and to keep people safe and free from harm.

There were sufficient staff to meet people’s needs. There were robust induction, training and supervision programmes in place to ensure staff had the knowledge and skills to meet people’s needs.

The management team undertook regular checks on the quality of care provided, and attended meetings to discuss the care provided to people. Where it was identified that improvements were required, the registered manager ensured these were implemented.

There was open and transparent communication amongst the staff team, and with people’s relatives. There were mechanisms in place to obtain feedback from people and their relatives about the care their received. Staff were encouraged to express their opinions about the service and to suggest ways of improving the care delivered.

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People using the service told us that they were generally well treated by staff and their health and social needs were met. Their relatives confirmed this. We saw that people using the service received the care and support they needed to sustain a healthy and reasonable quality of life in a safe, clean and comfortable environment.

Comments we received from people included "Yes the memory games are good. They do a lot here to keep the memory going and they are well looked after. They do as much as possible to make their stay as comfortable as possible for the rest of their time they have left".

"My cousin is cared for here and I visit regularly. He is always happy and looks well cared for. Having worked in the nursing profession, I think the care is excellent".

"The safety and dignity of my relative appears to be adequate. I would say that the emphasis is on feeding and washing. The making of paper hats and cards is demeaning. People with dementia are not children. Overall the home is caring and most of the staff are caring".

People said they were involved in choosing the type of care and support they needed and when they needed it. We were told "The staff at Hamiltons are kind, gentle, happy and caring. Nothing is too much trouble. What a good atmosphere".

Comments we received from relatives included "I find the staff experienced, kind and very caring towards the patients. When I ring up or visit most staff are very aware and up to speed on my relative's condition and welfare. She is always clean and tidy and her bedroom is immaculate. I am very happy with the care, the home and it is very nice indeed".

"Hamilton House is a really lovely home. The staff are always welcoming and pleasant to everyone. Everyone is treated with great respect and they are always patient and willing to listen to the clients. My mother is always clean, well-cared for and we have no concerns about her welfare".

People's opinions were encouraged and sought throughout our visit and generally acted upon. Relatives were in frequent contact with the home and encouraged to put their views forward regarding the service provided.

The records and care practices we saw showed us that peoples' preferences, choices and wishes were recorded and where possible met to an extent although not in a particularly person centred way. The activities provided were focused on a group rather than individual environment and therefore people's individual preferences tended to defer to the group activity taking place. The home acknowledged this and we were told that they were developing a more person centred approach to the way they delivered the service.

The home endeavoured to work with other providers to deliver a cohesive and joined up service, by providing relevant information in a timely way.

We received information alleging that people were living at the home who were not employed there. We spoke with the nurse and two care assistants during this unannounced night visit.

Staff accommodation was provided at the nursing home with one member of staff currently living there. Improvements could be made to enable staff to access their accommodation without going through the nursing home.

Staff said that they had completed training in safeguarding and were aware of their responsibilities to report issues and concerns to the manager to be investigated by the local authority. Staff told us that they had the required checks before they started work.

People told us what it was like to live a this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an 'expert by experience' (people who have experience of using services and who can provide that perspective).

To help us to understand the experiences people have, we used our SOFI (Short

Observational Framework for Inspection) tool during this visit. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people

spend their time, the type of support they get and whether they have positive experiences.

People who use the service we spoke with said that staff treated them with respect and maintained their privacy and dignity saying "staff call me by my name" and "staff give me the help I want and need".

Meals were seen to be unhurried and well organised with people receiving appropriate support with their meal. Comments about the food were positive and included "the food is lovely", "this is very nice", "this is tasty" and "lunch was delicious".

People told us they opportunities to join in with activities and outings as well as spend time in their room.

People who use the service and their relatives said staff came when they called and they thought there were enough staff. Comments about the staff included "staff help" and "they are nice people".

People we spoke with did not raise any concerns or complaints during our visit and said they would speak with staff who would help them.

Family members we spoke with had not made complaints and felt the service protected their relatives and kept them safe.

People who live at the home and their representatives told us that they are supported to make choices about their care, support and treatment. They told us that they had adequate and timely information to help them decide about their care and how they spend their daily life at the home. They told us that the staff always respected their independence, privacy and dignity.

People who use the service and family members told us that the home is meeting their assessed personal care needs. They said that they have timely access to healthcare and remedial services; including washing, bathing and doctor’s visits and the like. They said that they are satisfied with the service provision and delivery. They said that personal care support is flexible and consistent.

People who use the service and others we spoke to who were acting on their behalf, told us that they felt safe. One person told us that “I came here unwell, now I’m getting better, staff were nice, food is good, and I get my medicine on time”. A visitor acting on behalf of a resident told us that “she was involved in her care plan, she is been looked after very well, she get lot of liquid food as advised by doctor and that she is contend”.