Cherry Tree Care Centre - 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

26 to 28 January 2026

Date assessment was published

6 February 2026

Date previous assessment was published

27 February 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Pre‑admission assessments were in place and included relevant life history information. Care plans were generally person‑centred and reviewed at least monthly, with updates made in response to changes in need. However, a small number of care plans require greater detail to fully reflect individual needs. Occasional use of copied review text was identified; while no inaccuracies were found, this practice is not aligned with best practice and is being addressed. Daily care notes were personalised and generally of good quality, with continued improvement encouraged, particularly in relation to personal care documentation.

Mental Capacity Assessments (MCA) were present but require improvement in quality and completeness. In several cases, decision‑specific detail was insufficient, and there were occasions where additional assessments would have been appropriate. Deprivation of Liberty Safeguards (DoLS) and Do Not Attempt Resuscitation (DNACPR) documentation was appropriately recorded and reflected within care records, with clear evidence of oversight where conditions were attached.

Risk assessments, including Waterlow scores and Personal Emergency Evacuation Plans (PEEPS), were up to date and generally of good quality. It was noted that some planned welfare checks were not consistently completed, and management has been advised to  strengthen oversight through planned care monitoring to ensure required checks are undertaken.

Residents and relatives reported feeling safe, and staff demonstrated awareness of safeguarding responsibilities and reporting processes. Safeguarding policies were current and accessible, with clear logs of concerns and Care Quality Commission (CQC) notifications. However, several safeguarding enquiries were ongoing at the time of assessment. These identified weaknesses in managerial oversight, including insufficient investigation, incomplete follow‑up actions, and failure to update risk assessments after incidents. Further learning is anticipated, and additional management support has been recommended, and subsequently implemented, to strengthen incident analysis and oversight.

Staff recruitment files were well organised, with appropriate checks, including Disclosure & Barring Service (DBS) clearance in place. Induction processes followed recognised frameworks, and training compliance was at 100%, supported by clear records and oversight.

Medicines were managed safely, with appropriate storage, temperature monitoring, accurate Medication Administration (MAR) records, and up‑to‑date policies. Medication audits demonstrated effective governance with competency checks being undertaken 6 monthly (as per Stockton-on-Tees Borough Council (SBC) contract).

Infection Prevention and Control (IPC) arrangements were generally robust, supported by regular audits and a 5‑star food hygiene rating. However, issues were identified in some bathrooms, including unclean equipment and damaged pull cords, representing an IPC risk. Immediate action was taken to address the unclean equipment.

The environment was secure and well maintained, with clear fire exits, appropriate equipment checks and effective visitor controls. A dementia friendly environment was noted, and the home have completed the dementia friendly home guide (as per SBC contract). A manager's audit file was reviewed, containing a clear index, frequency guidance, and an aligned filing system. Evidence demonstrated that audit findings were discussed in supervisions and staff meetings, with associated lessons learned reports. A wide range of audits were in place, including IPC, food hygiene, skin integrity, MCA and DoLS, DNACPR, maintenance, kitchen, and domestic audits.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The Provider will complete an action plan for all areas identified that require improvement and the Quality Assurance & Compliance (QuAC) Officer will monitor progress against this to ensure the expected standard has been achieved and the acting manager receives support from more senior colleagues. Additionally, work will continue in relation to the ongoing safeguarding enquiries and any actions required monitored by the relevant team.

Level of Quality Assurance and Contract Compliance Monitoring

Level 2 - Moderate concerns - supportive monitoring

Level of Engagement with the Authority

Since the last PAMMS assessment the home has continued to see changes in management. The current acting manager is becoming acquainted with the role and has been supported by colleagues so far, further support has been identified as being required and the QUAC will maintain oversight over this. The home is currently under level 2 monitoring as a result of this and the current open safeguarding enquiries. A good working relationship is held between the provider and the QUAC officer.

Engagement and Support from Transformation Managers

Cherry Tree have a positive and engaging relationship with the Transformation Team, and participate in a number of opportunities, such as Provider Forum, activity networks, activities in the community, training, and most recently registered interest in supporting care home research. The Transformation Team will continue to encourage and engage with the acting manager and wider staff at Cherry Tree to sustain the positive work within the home.

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

Date of inspection

1 October 2024

Overall rating

Good