Victoria House - PAMMS Assessment Report

The home has recently transitioned to the Nourish electronic care planning system. Care plans were person‑centred, clearly outlining residents' preferences, life histories (via the biography and additional information sections), Deprivation of Liberty Safeguards (DoLS), and mental capacity.

Regular meetings for residents and their families are held, with upcoming dates clearly displayed on notice boards. The Resident of the Day approach includes contacting next of kin to gather their views, preferences, and any updates. The manager also operates an open‑door policy, ensuring easy access for residents, relatives, and staff.

During the assessment, family and friends were seen visiting throughout the day. Care plans showed that residents were supported to spend time in the community, either with staff or their families.

The home provides a wide range of activities led by two dedicated Activity Coordinators, with a varied programme displayed across the home. During the visit, residents were observed enjoying The Dodgers, Musical Moments, and interactive games such as balloons and skittles. Activity photos are regularly shared on the home's Facebook page.

Staff consistently demonstrated dignity, respect, and kindness, encouraging independence and maintaining positive relationships with residents.

During mealtimes, staff showed good knowledge of residents' dietary needs and used show plates effectively. The daily menu was clearly displayed, and residents were given free choice, with all alternative requests accommodated.

Professionals visiting during the assessment provided positive feedback.

A key worker system is in place, and staff were aware of the residents they were allocated to support. They described tasks such as contributing to care planning and helping with shopping for toiletries and clothing. One staff member warmly noted that, regardless of allocation, they strive to provide the same dedicated support to all residents whenever needed.

Notice boards clearly outlined how residents could give feedback or raise concerns, including options for doing so if they felt uncomfortable speaking directly with staff.

A staff survey was completed in December 2025; however, the required annual resident, relative survey under local authority contract has not yet been completed. Plans are in place to address this within the next few weeks.

The Daily Kitchen Diary showed that all required checks, including fridge and freezer temperatures and food temperature monitoring, were completed and within expected limits. The Maintenance Manual records water, wheelchair, electrical, and general health and safety checks, all of which were up to date.

Staff audit 10% of care plans monthly, with management reviewing findings, assigning actions, and confirming completion. The manager also conducts additional audits, including daily walkarounds and organisation‑led quality audits. All servicing and maintenance tasks were within date, with current certifications held on file.

Hand hygiene during mealtimes and medication rounds did not meet required standards. Staff did not wash or sanitise hands between tasks, and electronic devices were visibly unclean. Despite this, overall Infection Prevention Control (IPC) measures were satisfactory.

Medication administration was observed to be safe and person‑centred, though competency checks are being completed annually rather than every six months as required by local authority contract.

Observations showed positive interactions between staff and residents, who appeared relaxed and secure. The home maintained a calm atmosphere throughout the assessment, with clear evidence of strong, supportive relationships.

Staff confidently described different types of abuse, the signs to look for, and the steps they would take to report concerns, including informing management and external agencies. They were also familiar with the whistleblowing policy.

The home environment was clean, well maintained, and dementia‑friendly. The home holds a 5‑star Food Standards rating (September 2024).

IPC information is clearly displayed throughout the home, including guidance on handwashing and winter precautions. An Infection Control Champion is in place, and hand sanitiser and paper towels are readily accessible.

The medicines room was clean, secure, and equipped with suitable storage systems. However, there were some gaps in the fridge temperature records, and one expired PRN (as‑required) medication was identified, although it had not been administered.

The home includes several dementia‑friendly features such as colour‑contrasted handrails, toilet seats, bedroom doors, and clear bathroom signage. The manager is working with local authority to complete the dementia‑friendly guide, with several planned improvements to further enhance the environment. Additionally, two staff members act as dementia coaches within the home.

Staff visibility during the assessment was strong, with team members present throughout the home and engaging actively with residents. Call bells were heard infrequently, and when they did ring, responses were prompt.

Staff files contained the required recruitment documents, but some checklists were incomplete due to documents being stored on online portals. Advice was provided to update the checklists to reflect this. Reference verification was not evidenced, as this is handled by the organisational recruitment team. Only minor recommendations were made.