Primrose Court 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

18 to 20 August 2025

Date assessment was published

17 September 2025

Date previous assessment was published

30 October 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were person centred and written in a respectful manner, were reviewed monthly at minimum and were seen to have been reviewed in response to changes in need or to incorporate new information provided by professionals. They clearly documented the individual approaches required for each resident as well as information relating to what is important to the person such as family and life history. Regular assessments were noted to take place and Personal Emergency Evacuation Plans (PEEP) were seen to contain accurate information and were also reviewed regularly. Information gathered within these assessments was included in care plans and escalation of concerns to other professionals was evidenced. Daily notes were person centred and contained good detail including food and fluid records and an overview of the individuals' presentation that day.

Observation and discussion confirmed that residents are treated individually and their privacy and dignity respected. Residents, where able, had access to manage the security of their bedrooms independently, and bedrooms were well personalised. Unwise decisions were supported appropriately, and residents' well-being appeared to be well maintained. Those spoken with confirmed they felt they and their loved ones were safe and well looked after. Staff were aware of the different types of possible abuse and were able to explain possible changes in an individuals' behaviour as a result of abuse, and how they would handle this.

Staff were noted to follow appropriate practice in relation to food hygiene and infection prevention and control, with hand washing undertaken and Personal Protective Equipment (PPE) worn. They were rated 5 (very good) following a food hygiene assessment conducted by the Food Standards Agency in February 2025. Menus were seen to be healthy and balanced and residents were seen to be offered choice over meals and portion sizes and supported with personal requests.

Staff files contained records largely consistent with appropriate recruitment checks including right to work documents and references. Files contained completed induction checklists which covered policies and procedures as well as training, including the care certificate and required sign off by the inducting officer. Appraisals take place annually and supervisions bimonthly, as per contract. There is a matrix in place for the year with the preplanned schedule, which was seen to match the completed records on file. A training matrix is in place and identifies training compliance to be at 100%.

Medicines were stored securely and appropriately in lockable medicine cabinets, stored in locked medication rooms. Controlled drugs are stored in separate, locked, cabinets, within the medication rooms. A medication policy was in place and reviewed recently in June 2025, the policy includes homely and covert medications. Medication competencies were being conducted annually at minimum (in line with NICE guidance), though the Stockton-on-Tees Borough Council contract requires them to be undertaken 6 monthly. A monthly medication audit is being conducted using the NECS (North of England Commissioning Support) medicine optimisation teams' template and their most recent audit score was 86.5%. Medication documentation, for example front covers, Medication Administration Records (MAR) charts were being completed appropriately. There were a number of occasions were the special instructions on medication labels (for example do not consume grapefruit) did not match the MAR chart and on discussing this with the manager, they advised this was something they were already remedying with the their new pharmacy supplier, following a recent change.

The home is well equipped taking into consideration the needs of their residents, promoting independence and enrichment and the associated risks considered. There is a dementia friendly environment with appropriate use of décor and orientation signage throughout. The home have completed the Dementia Friendly Care Home Guide, as required as part of their contract. The premises was secure with corridors and doorways free from obstruction. Equipment was seen to be in good condition and appropriate servicing certification noted to be in date and on file. Safeguarding information is displayed within the home and contains contact details for the regional local authorities.

There is a 'managers monthly audit' file in place which contains an index outlining the area of audit and frequency, the audits covered several areas and were seen to be done at the required frequency, or more often. The homes maintenance, domestic and kitchen audits are completed using Acticare books which contain a section for completion by the manager to evidence oversight, however the provider has developed a separate, more in depth, audit of these which are completed monthly. The audits reviewed appear mostly to have been conducted robustly, with areas of improvement identified and recorded, along with follow up actions such as repair work or staff supervisions recorded, though the 'weekly' tasks in the domestic and kitchen books don't appear to be completed on a weekly basis and this had not been identified. Discussion with staff informed that these tasks are being undertaken at intervals set by the home rather than following the template of the book and recommendation has been given to review this to ensure that the recording template reflects the planned schedules.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address minor areas identified for improvement to ensure full compliance which will be monitored by the Quality Assurance and Compliance (QuAC) Officer.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns - standard monitoring

Level of Engagement with the Authority

The provider is responsive to requests from the Local Authority and liaises closely with their QuAC Officer. Performance Dashboard submissions are made in a timely manner, and queries are responded to promptly. There have been some recent changes in management, and the QUAC and Transformation Manager are supporting with this.

Engagement and Support from Transformation Managers

The care home engages with the Transformation Team across a number of initiatives. Although the current acting manager hasn't participated in the Well Led Programme, the care home has collectively engaged with a number of other opportunities over the last year, including the Activity Coordinator Network and training. The care home brings residents into the community for events hosted by Stockton-on-Tees Borough Council and other care homes in the Borough.

The Transformation Team will link in with the care home managers to discuss leadership development opportunities and peer support networking to ensure ongoing consistency in practices across the service.

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

Date of inspection

4 July 2023

Overall rating

Good