Ingleby Care Home - 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

17 and 18 February 2025

Date assessment was published

17 March 2025

Date previous assessment was published

3 January 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Discussion with residents and observation of staff interactions confirmed that residents are treated with respect and their privacy and dignity is maintained. Staff were observed to speak to residents advising them of any interventions they were supporting with, gaining consent and offering reassurance throughout. Family spoken with confirmed that they feel the residents are supported and respected. A relatives meeting had been held in January, but there was no evidence of a residents meeting. A mealtime experience survey had been carried out in January, other than this there was no evidence of resident's opinions and wishes being sort to help shape the service. Discussions with residents confirmed they felt staff were approachable and they would be comfortable to raise any concerns, however this had not been necessary.

Planned care did not always reflect the care identified in assessments and care plans, for example one person's nutrition risk assessment stated that the person should be offered fortified drinks regularly in view of weight loss however there was no evidence of this occurring. Personal Emergency Evacuation Plan's (PEEPs) did not contain the required information relating to the persons diagnosis and presentation. The section for assessments, where a person had hearing or visual impairments were not always completed despite the person having impairments. Hospital passports are produced by the system using a summary of the information held within the care plans. Regular weights were not being completed and information relating to Malnutrition Universal Screening Tool (MUST) scores was seen to be inconsistent. Fluid records were regularly low and there was no evidence of any actions being taken, despite care plans being in place for fluid goals.

Staff were observed following good practice with regards to cleanliness and infection control. Appropriate personal protective equipment (PPE) was seen to be worn at all times, correct procedures for donning and doffing were carried out and staff were seen to observe good hand hygiene. Staff were seen to be observing bare below the elbow guidelines and a different colour of PPE was seen to be used for food service.

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 round was carried out in a safe and person-centred manner however good hand hygiene practices between residents was not always evident. Gloves were worn and changed between each resident however hands were not sanitised every time gloves were removed. Medication changes were recorded appropriately, in line with good practice guidance and the majority of non-administration codes were recorded appropriately. A robust ordering process was in place with medication levels checked prior to ordering. The checking in process incudes a cross check between the new Medication Administration Record (MAR) the order and current MAR to identify any discrepancies.

Access to the Home is secure and visitors are let in by staff through a locked front door. A visitors' book is used and the identity of the visitor is checked. Risk assessments were in place where specific needs were identified for a Residents and equipment required. The New Manager is working closely with the Community Link Worker from the Live Well Dementia Hub to support residents living with dementia.

There was a lack of evidence in the staff files to support that regular one-to-one supervisions and an annual appraisal were taking place. It is a contractual requirement that staff receive six supervision meetings a year together with an annual appraisal, to support performance management. The Company is using a new training platform, My Hippo. The training matrix was viewed during the assessment and evidenced that overall compliance in mandatory training was over 94%, which well exceeds the contractual requirement of 80%.

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. There was no evidence of low-level complaints being recorded and reviewed for trends. Staff meetings have been held on a regular basis, dates of the meetings are displayed in advance together with an agenda, minutes are taken and circulated.

There have been no residents meetings held and only one relative meeting during the last 12 months.

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 3 - Major concerns - enhanced monitoring and proactive intervention.

Usually, an overall Requires Improvement PAMMS rating would have Level 2 Monitoring, but the Service has recently been in the Responding to and Addressing Serious Concerns (RASC) process and received four breaches in a recent Care Quality Commission (CQC) inspection. Current occupancy is at a concerning level, the Home Manager has resigned and there is a new Regional Manager in place. This is reflected in the above monitoring level

Level of Engagement with the Authority

The Manager engages well with the QuAC Officer and is responsive to requests. However, the submission of performance information has been inconsistent.

Engagement and Support from Transformation Managers

The Manager continues to engage with the Transformation Team, attending the care home provider forums and allowing the activity coordinator the opportunity to network with peers across Stockton-on-Tees. Although the Manager would like to take up new opportunities, she feels she doesn't have the capacity to do so at the moment but is keen to explore some initiatives in the near future. The Transformation Team visit regularly to support the Manager and wider team and will continue to help with quality improvement activities.

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

Date of inspection

29 November 2024

Overall rating

Requires Improvement