Piper Court - 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

18 to 20 August 2025

Date assessment was published

4 September 2025

Date previous assessment was published

21 October 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans viewed were inclusive and non-discriminatory and were structured in a way to preserve the well-being of the resident. Front pages had a good life history profile of the resident, which included their goal though this was not always evidenced of being acted on. Care plans were written with the resident in mind and had good detail of preferences, abilities and level of independence, behaviour triggers, likes and dislikes.

Residents spoke of how happy they were in the home, that they liked the staff and that they feel settled. Residents particularly liked how staff come and speak to them and are respectful and polite. Observations throughout the assessment on moving around the home evidenced good relationships and familiarity between staff and residents. Through observation staff were seen to respect preferences, took time offer choices and were overheard considering residents usual routines.

Though there was evidence of resident and family involvement in initial care plan creation, this was not followed through into monthly reviews. Care plans and risk assessments were being reviewed monthly in line with contractual requirements, however monthly review notes had limited quality, with frequent examples found of notes being vague and generic. A Resident of the Day meeting structure is used by the home, but there was limited evidence of this being utilised by staff and lacked quality detail when completed. Daily notes were seen to be added throughout the day, and were sometimes personalised, but not always, lacking further detail at times.

The home environment was tidy, free from clutter and fresh smelling. It was noted that communal areas could do with a cosmetic upgrade and plans had been put in place to begin this process. Bedrooms were personalised with items from home. Dementia appropriate adaptations were seen throughout, including pictorial signage, adaptive equipment, and coloured handrails and toilet seats. The home has not yet started their Dementia Friends accreditation.

Evidence was seen of regular maintenance and safety audits and testing. All audit books were seen to be completed weekly or monthly as required. Appropriate noting was seen for entries not completed, or problems found, with notes being updated and signed off once corrected. Additional audits are completed by the home manager, regional manager and the Akari Quality team.

Good infection prevention and food hygiene practices were observed throughout the assessment, including correct use of Personal Protective Equipment (PPE), disposal methods, and handwashing. Staff were all seen to be bare below the elbow. There is an Infection Prevention Control (IPC) display in the main corridor, and this names the allocated IPC champions for the home in line with contractual requirements.

Medication rounds observed were completed to a good standard, high standards of hand hygiene were used and a good level of interaction was witnessed. The staff member knew the residents, the medication, and how they take it, but still cross-referenced this with the Medication Administration Record (MAR) before administration. Storage of medications, the medication trolley, and the medications room were all appropriate and seen to be locked when not in use. On observation, the trolley was well organised by resident, medication room and fridge temperatures were recorded daily, and medication labels matched the MAR with clear labelling. Correct codes were used for most MAR's viewed; instances of non-administration were minimal. Pro re nata (PRN's latin for 'when required') were noted with the time. Controlled drugs were signed by two members of staff. Staff competencies were viewed and were in line with contractual requirements. There was evidence seen of both the manager and regional manager completing regular medication audits.

Staff confirmed they receive annual refresher training and were well versed in the Mental Capacity Act, Deprivation of Liberty (DoLS) and safeguarding. Staff all carried Mental Capacity Act cards, along with identifying displays in corridors, gave good examples of how they put this into practice. All staff, regardless of role, knew of the purpose of DoLS and that they must be aware of any applicable conditions. Staff all knew of safeguarding practices, how to raise concerns of abuse should they need to, and where to locate the whistleblowing policy.

Staffing levels at the time of the assessment were good, staffing visibility around the home was to a good level. There had recently been an uptake in new staff, all were evidenced to have taken part in a comprehensive induction and probation, which included use of the Care Certificate. Supervisions were not being completed consistently in line with contract at the time of assessment, though all staff had recently had an annual appraisal. At the time of assessment training completion was at 94%.

Plans and Actions to Address Concerns and Improve Quality and Compliance

A small action plan is being created by the provider to address any areas of improvement found. This will be monitored through reviews and contract visits by the Quality Assurance and Compliance (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 provider has a good level of engagement with the Local Authority. The manager is responsive to both QuAC, Transformation, and Medicines Optimisation teams.

Engagement and Support from Transformation Managers

Piper Court engages on a high level with regards to networking and training. The activity coordinators attend network meetings, have participated in workshops and training and bring residents into the community for events. The home has previously taken part in some research projects, and this will be encouraged further with the new leadership team.

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

Date of inspection

4 June 2025

Overall rating

Good