Woodside Grange - PAMMS Assessment Report

The home has now fully transferred over to electronic care planning. Care plans are individually tailored and person centred. Each resident has a front page which contains pertinent information such as name, date of birth, room number, NHS number, date of admission, resuscitation status, Deprivation of Liberty Safeguards (DoLS), photograph, allergies, GP details, next of kin and emergency contact. The home has a range of care plans and assessments in place to ensure residents needs are adequately met and their welfare protected. Care plans and risk assessments are reviewed at least monthly and with any change in need and updates as required.

Mental Capacity Assessments (MCA) were seen to be in place for residents, those residents who were deemed to lack capacity had appropriate DoLS authorisations in place. Best interest decisions were also seen to be in place such as use of lap belt on wheelchairs, medication etc. DoLS dates of expiry were seen to be recorded. 

Care plans contain details of any Do Not Attempt CPR (DNACPR) and associated paperwork uploaded; decision were seen to be reviewed annually. Care plans also contained details of resident's nutritional requirements and Malnutrition Universal Screening Tool (MUST) assessments in place and are reviewed monthly.

Although residents had an allocated key worker which was recorded on their care plan, this information was not readily available for residents and relatives, and staff were unsure on the key worker system. This was discussed with the home manager.

Management of medications was found to be good; the home had recently moved over to Electronic Medication Administration records (eMARs). Care plans detail how residents like to take their medications; medicines were found to be stored and administered safely and appropriate records maintained.

Staff interactions were observed to be genuine, positive, and respectful. Residents' general wellbeing was observed to be maintained, residents looked well-presented and bedrooms were seen to be personalised.

Safer recruitment practices were followed within the home, staff files contained an application form, with employment history and evidence of gaps in employment history explored, interview notes, at least two references, Right to Work checks (where required), and Disclosure and Barring Service (DBS) Certificate information. Staff were found to have the required knowledge, understanding and training for the role. Staff confirmed they received appropriate induction at the start of employment and received ongoing support via regular supervision, training, and annual appraisal. An agency file was in place and contained the staff members agency profile, including photograph, details of checks in place such as DBS, right to work and induction. Appropriate documentation was in place for visiting professionals. Training compliance at the time of the assessment was 94.9%. The home was staffed in line with the dependency tool staffing requirements.

The home was found to be safe and secure however some areas of the home required attention to be inline with infection prevention control guidance, such as bathrooms with rust on shower chairs and handrails around the home that were significantly chipped. The home has completed the Dementia Care Home Guide and maintained a rating of 5 on their most recent Inspection from the Food Standards Agency.

Appropriate service certification was in place and in date such as gas safety, fire system maintenance and servicing, emergency lighting, legionella checks etc.

Information is available in the home to support people to raise any concerns such as complaints, safeguarding, and whistleblowing information. Meetings and surveys are in place for staff, residents, and relatives. The manager has appropriate logs in place to record complaints, compliments and safeguarding concerns however the lessons learned from these is not consistently completed.

A range of audits were in place including catering, mattress, mealtime experience, daily walkaround and Infection Prevention Control (IPC) however the environmental IPC issues were not identified in the audits. Regular care plan audits were not undertaken by the management of the home. A home improvement audit was in place however not all identified work was seen to be included.