Church View Nursing 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 2025 to March 2026.

Date of inspection

8 to 10 September 2025

Date assessment was published

23 September 2025

Date previous assessment was published

27 January 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans contained information on how the individuals wanted to receive their care which evidenced their involvement in care planning and this was reflected in daily notes. The online care planning system has two sections to gather life history and detail on what is important to the individual, 'who I am' and 'about me', which were often lacking in detail or incomplete. This was identified during the last assessment and improvements made had not been sustained. Assessments were seen to contain conflicting information and information was not always transposed into care plans appropriately, for example several medical diagnoses were noted to have been captured in some assessments but not others. Daily notes were mostly seen to be of good standard with detailed food and fluid records and professional visits and any escalation of concerns to professionals recorded.

The audit trail on the online care planning system showed that monthly reviews were being recorded however the review notes here were often copy and pasted from previous reviews, with the document itself not appearing to have been reviewed (for example not updated with change in need, or errors not identified and corrected). There were also occasions whereby the review note contained information that should have been added into the care plan itself. Again, this was identified during the last assessment and improvements not sustained. A key worker system was in place but not being utilised effectively as residents and relatives were often unaware of who their allocated workers were.

Safe care delivery was observed and those spoken with reported feeling safe and well cared for in the home. There were no reports of involvement in safeguarding concerns, but all spoken with reported feeling able to raise any concerns with staff and management should they need to. Observation and discussion confirmed that residents are treated with dignity and respect, and their privacy was maintained. Choice was seen to be offered and decisions respected, with gentle guidance and encouragement if needed. An activities schedule was displayed and activities were observed such as one to one activities, quizzes, outings, and pet therapy with the resident rabbit.

Appropriate food hygiene practices were observed and a Food Standards Agency inspection done in June 2024 was rated 5 - 'very good'. Residents and relatives confirmed there was access to food and drink outside of mealtimes.

Staff files were mostly seen to contain the required checks and paperwork, for example a photograph of the individual, right to work checks and references, which were both noted to have been signed and dated to confirm the original document had been seen or the reference verified by phone. Some minor amendments to the process were made during the assessment as a result of feedback given. Staff supervisions and appraisals were seen to be conducted at the intervals set out within the contract.

Medication rooms and trollies were clean and tidy and storage was seen mostly to be safe and appropriate. Controlled drugs were stored appropriately and records were seen to be completed, with only a small number of instances whereby a second signature was missing. Overall medicines were being safely stored and administered with appropriate records in place. Medication competencies are carried out 6 monthly, in line with contract. A monthly medication audit is being conducted using the North of England Commissioning Support (NECS) medicine optimisation teams' template, all of which scored above the 85% threshold set by medicine optimisation. Their most recent audit in August was undertaken by the meds op team themselves and was scored at 89%.

The premises was noted to be secure with entry and exit via keypad and doors appropriately locked. Fire escapes and corridors were free from obstruction and staff were identifiable by uniform and some wore identification badges. The home has completed the Dementia Friendly Care Home Guide (as per contract) and had a dementia friendly environment but continues to work to improve this. Equipment was seen to be in good condition and appropriate servicing certification noted to be in date and on file.

The homes maintenance, domestic and kitchen audits are completed using Acticare books which contain a section for completion by the manager to evidence oversight, this is completed alongside a separate, more in depth, monthly audit of each book which has been devised by the provider, as well as several other regular 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. The Quality Assurance and Compliance (QuAC) Officer will monitor progress against this to ensure the expected standard has been achieved. It is noted that improvements made following the assessment in December 2024 have not been adequately sustained and there will therefore be and additional focus on these areas and the Provider will be required to evidence a plan for sustained improvement and oversight of the same.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns - Standard Monitoring

Level of Engagement with the Authority

There have been further managerial changes within the home which are being supported by the Operational Director and ongoing oversight of this by the QuAC. Despite the changes in management, engagement continues to be positive with timely submissions of information such as monthly performance dashboards.

Engagement and Support from Transformation Managers

The care home engages with the Transformation Team across a number of initiatives including the Activity Coordinator Network and training, such as mediciness optimisation. The care home brings residents into the community for events and engages with local activities.

The Transformation Team will continue to engage with the care home to promote other opportunities, such as leadership development, networking and research projects.

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

Date of inspection

23 April 2025

Overall rating

Good