Chestnut Lodge - 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 2025 to March 2026.

Date of inspection

10 November 2025 and 11 November 2025

Date assessment was published

24 November 2025

Date previous assessment was published

5 November 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were seen to be person centred and written from the resident's perspective. Care plans included resident's desired outcomes, their strengths, actions for staff, and gave detail on resident preferences on how they like to be cared for. Good detail was seen of what residents like to talk about and how they like staff to interact with them. Family involvement was seen across care plans, and families spoken with backed up this inclusion. Information around the home was in an accessible format.

Interactions observed around the home were good. Resident choices were respected, staff supported with residents who had capacity to make unwise decisions. Feedback from families spoken with was exemplary. Staff gave constant reassurance to residents, explained what they were doing clearly, and always asked for consent. Residents in the home at this time are largely non-verbal, and the staff showed a good array of knowledge of how to read verbal cues to communicate effectively.

Care plans are reviewed monthly, though review notes are limited with majority having no note or a basic note. The home has a specific 'monthly review' plan following previous feedback, though this was again either not completed or completed as a basic summary of the resident rather than a summary of the month. Daily notes were recorded often and varied with needs. Overall daily notes were personalised, person centred and contained good detail on the level of support offered and given.

The home has allocated keyworkers, as per contractual requirements, which they name buddies. Residents have two buddies, one care and one named nurse. Families of residents were aware of the buddy system, and this is clearly identifiable in bedrooms with a poster listing their responsibilities.

Staff had a good knowledge of resident preferences for food and drinks, and kitchen staff particularly knew without needing to reference care plans. Portion size was good, and menus were balanced. Food hygiene and infection control practices were good. The home's current food hygiene rating is 5. Staff were observed as bare below the elbow, hair tied back, and using the correct colour coded Personal Protective Equipment (PPE). Hand hygiene was good with correct use of gloves. Appropriate waste management processes were followed. The home has an allocated Infection Prevention and Control (IPC) Champion, as per contractual requirements.

Medication rounds observed were good, staff were knowledgeable of resident preferences and needs and spoke to them with respect. Good hand hygiene was observed, and the trolley was cleaned before and during use. Medications are in blister packs stored in a locked medication trolley which is secured to the wall in the office. Controlled drugs are stored in an appropriate locked cupboard, and the count book was signed by two members of staff, with regular audits and stock checks. Medication administration records were completed to a good standard, correct codes were used, no missed entries, crossing out, or overwriting were seen, and all had good standard of front covers in place. Regular manager audits take place, actioned accordingly. Staff competencies are completed 6 monthly, in line with the contract requirements.

All staff confirmed they had received training on the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLs), and safeguarding, and were able to explain their purpose, and gave good examples of how they put them into practice for the residents in the home. Staff were all very knowledgeable on the correct processes to follow if they had concerns to be raised.

The premises were seen to be secured and safe. Corridors were free of clutter, there was no inappropriate storage, external doors were alarmed, and windows had restrictors. An audit is in place monthly to monitor environment risks. The home has recently undertaken dementia friendly consultation and has commenced the Dementia Friends accreditation; the home was in the process of adapting communal spaces to meet these needs. Fire risk assessments are in place and seen to be reviewed annually. There are some decor updates that need to be made for the overall presentation of the home; however, the home was clean and tidy throughout with no evidence of malodours.

A comprehensive induction process is in place, which utilises the Care Certificate. Staff confirmed they have supervisions and appraisals, on review of the supervisions matrix and paperwork these were not taking place regularly and were not compliant with contractual requirements. No staff reported concerns with staffing levels, and when the rota was viewed against the dependency tool, staffing was appropriately split.

A range of audits and servicing certificates were in place and in date, and the manager also undertakes a range of weekly and monthly audits. Maintenance, domestic, and kitchen audits take place daily and were recorded, with no gaps seen. Cleaning sheets are in display around the home which are coloured in once completed, one per room and for each communal space, and include daily, weekly, and monthly tasks.

An open-door policy for the manager and nursing staff is utilised by families, and families advised that any concerns they do raise are handled timely. Families gave good feedback on communication by management and staff. Staff also reported feeling highly supported by the management structure. Annual surveys are taken for residents, families, and staff.

Plans and Actions to Address Concerns and Improve Quality and Compliance

A small action plan is to be created by provider to address the few areas that were found that Require Improvement, which will be assessed by the Quality Assurance & Compliance (QuAC) Officer through contractual visits.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns, minor concerns - standard monitoring

Level of Engagement with the Authority

The provider has a good level of engagement with the Local Authority, is responsive to emails, and is always on time with submissions.

Engagement and Support from Transformation Managers

Chestnut Lodge engage with the Transformation Team in a number of ways, including the Well Led Programme, training opportunities, Provider Forum, and Leadership Networks. The staff team are always open to conversations about opportunities and look to how they can participate in the initiatives suggested to them.

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

Date of inspection

9 March 2023

Overall rating

Requires Improvement