Allison House - PAMMS Assessment Report

Stockton-on-Tees Borough Council (SBC) are utilising the Provider Assessment and Market Management Solutions (PAMMS) in our quality assurance process. PAMMS is an online assessment tool developed in collaboration with Directors of Adult Social Services (ADASS) East and regional Local Authorities. It is designed to assist us assess the quality of care delivered by providers.

The summary table below detail the PAMMS assessments undertaken for the contracted Older Persons (OP) care home throughout April 2024 to March 2025.

Date of inspection

24 February 2025

Date assessment was published

19 March 2025

Date previous assessment was published

March 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

All residents had copies of an "about me" booklet which is completed on admission by residents or families. There was evidence of the information from this being used across all care plans to support person centred care. Care plans were structured in the third person and though brief, were clear and concise on how residents prefer their care, behaviours they may exhibit, their likes and dislikes, family involvements and their life histories. There was evidence of this information being used consistently across all plans viewed. The home is in the process of transferring all care plans over to an electronic system. Care plans on the new system were also viewed and were seen to have the same standards of detail included. Care plans had a signature box at the bottom of the plans, this was sometimes completed by named nurses. There was an additional box for a significant other to sign, with instruction to specify, but specification was not always given so it was difficult to confirm who had signed on their behalf. Family spoken with confirmed that can give feedback on the quality of service delivered, there is a suggestions box where they are able make comments and the Manager is always available to discuss any issues. Family members spoken with advised they had not had cause to raise a concern but would be happy to do so. The Manager confirmed that a relatives survey is planned for the next few months.

Care plans and risk assessments are in place for Braden and pressure care, repositioning and moving and handling, food and fluids, Malnutrition Universal Screening Tool (MUST) and Personal Emergency Evacuation Plan's (PEEP's). All risk assessments and associated plans were reviewed monthly. Plans gave instruction on what to look out for and at which point concerns require escalation. All residents have a health passport in place. The residents at Allison House are living with Dementia and therefore family members and friends are fundamental to the care planning process. Family members spoken with confirmed their involvement in formulating the initial care plans and having "regular discussion" about ongoing care needs. However, there is a lack of documented evidence of these discussions.

Staff confirmed that they have training on the Mental Capacity Act, safeguarding, and Deprivation of Liberty Safeguards (DoLS). Staff had good knowledge of all three and could explain how the training impacts their day to day practices All staff confirmed they have adequate training to support with infection control, including from the external nurse who visits to deliver refresher training. Staff knew the correct practices for waste management and explained colour coded bins and laundry, personal protective equipment (PPE), correct handwashing procedures and appropriate disposal of PPE and gloves.

During this assessment, the Medication elements of the PAMMS inspection were assessed alongside the North of England Commissioning Support (NECS) Medicines Optimisation Team and were scored in mutual agreement with the Quality Assurance and Compliance (QuAC) Officer whilst considering the observations and findings.

The Medication room was checked and found to be clean and tidy with medication organised per resident. Room and fridge temperatures were recorded and within recommended parameters. Medicines requiring refrigeration were stored appropriately, however the keys were left in the medication trollies.

Of the Medication Administration Record (MAR) charts sampled some handwritten entries did not accurately match the label on the medication. Several medications in the trollies were identified as being out of date. Although some protocols for medication as and when required (PRN) viewed were accurate and person centred others were missing, inaccurate or lacked person centred detail.

Patch application records were in place, completed with date applied, date removed and a daily check, however a rivastigmine patch did not have the correct rotation followed. Covert administrations were not clearly recorded, there is no way to distinguish between overt and covert administrations. Residents had refused some medication, but staff did not document that they had then tried to administer covertly.

Medication competencies had been carried out but not all 6 monthly in accordance with the Local Authority.

Recruitment records were viewed for five members of staff with varying lengths of service, carrying out different roles and including a Registered Nurse. Application forms had been completed documenting qualifications and employment history for all applicants. Disclosure and Barring Service (DBS) checks had been carried out and two references received prior to the employment commencing in all files except one where the new recruit started with an Adult First check only. None of the files viewed contained a Job Description and only four contained a current Contract. Of the files views two of the staff had not commenced a skills based induction despite being in post for a significant period of time. There was also no evidence of the Registered Nurse completing any induction programme. There was evidence that regular supervision meetings are being carried out and this was confirmed in discussion with Staff. Annual Appraisals are currently being carried out and are recorded on a matrix maintained by the Manager to monitor progress.

The Manager was able to evidence that they respond to complaints effectively and within the organisations timescales and complainants are kept informed of the progress. The complaints file includes copies of all correspondence and details of any investigations. Records evidenced that service improvements are made following findings in investigations, however there is no process in place to inform staff of lessons learnt. The Manager carries out a range of scheduled audits, these were found to be robust enough to identify any issues. The Medication audits are carried out by Nursing Staff and some inconsistency in quality was noted. The Manager confirmed that she intends to take a more prominent role in these going forward. All service information and safety checks are kept in a file which also contains a covering list of when certificates needed renewing, compliance is checked by the Manager as part of her Health and Safety audits. All appropriate certificates were evidenced and in date.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address the areas identified for improvement to ensure full compliance and improve quality. Progress towards meeting the action plan will be monitored by the QuAC Officer.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns, minor concerns - standard monitoring

Level of Engagement with the Authority

The Manager engages well with the QuAC Officer, is responsive to requests and submits performance information in a timely manner.

Engagement and Support from Transformation Managers

The Manager engages well with the Transformation Team and attends the care home Provider Forums. The activity coordinators are also highly engaged with their respective networking opportunities, linking in with other peers across Stockton for ideas and good practice to support their residents and have taken residents to community activities and events. The Manager participated in the pilot of the Well Led Programme.

Current Care Quality Commission (CQC) Assessment - Date of Report Publication and Overall Rating

Date of inspection

30 July 2022

Overall rating

Good