Millbeck Care 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

7 July 2025

Date assessment was published

21 July 2025

Date previous assessment was published

26 September 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were seen to be personalised and detailed personal information. Every resident has a front page with picture, room number and do not attempt cardiopulmonary resuscitation decisions. The status of Deprivation of Liberty safeguards and Liberty Protection Safeguards is displayed on the front page. The care plan provides an overview, including risks to be mindful of, preferences for conversation topics, a medical summary, a summary of care needs, necessary equipment and contact details.

Each resident has an 'About Me' section which outlines what is important to them, the people who are significant in their lives, how to best communicate with the resident, and their personal do's and don'ts. Live updates of care are updated as the day progresses, displaying an amber colour if overdue and turning green once completed. Care plans cannot display signatures from residents or their families because they are electronic; however, any discussions with residents or families were seen to be recorded in the monthly reviews.

Discussions with residents reveal a high level of satisfaction and a feeling of support within the home. They mention that the staff are approachable and helpful in every regard. Importantly, even when residents have their doors open, staff always knock prior to entering. Observations validate that the well-being of residents is a top priority, with all individuals seeming to be well looked after. Residents convey that their personal rooms contain all the essentials they require.

Care plans included associated risk assessments and residents had personal evacuation plans in place. Food and fluid intake charts were filled out throughout the day, noting the offerings and the amounts consumed. A health passport containing all relevant information could be generated from the care planning system. Care plans and risk assessments were reviewed monthly.

Residents spoken to felt that they would be happy to raise a complaint if needed and would speak to the staff. The manager is noted for maintaining an open-door policy for residents to discuss issues. The residents interviewed had not needed to lodge a complaint but believed they would receive support if it became necessary. Staff reported feeling able to report issues of poor performance or risks to people and feel they would be supported by management if they did so. They were all aware of whistleblowing and advised of the posters displayed in the home with direction on how to do this.

A variety of suitable audits are conducted by the manager and deputy manager. The Quality Assurance process is supported by the Regional Support Manager. Daily fire safety checks are carried out including the checking of escape routes, fire warning systems, emergency lighting and firefighting equipment. The manager contains a matrix for scheduled maintenance services and checks.

None of the residents interviewed were aware of whether they had been involved in a safeguarding process. However, when asked, they confirmed feeling safe and satisfied within the home. Staff were able to give examples of different types of abuse and describe how they would act upon them. Staff were aware of safeguarding and whistleblowing policies and knew where to access current versions. They were aware of external agencies to whom they could report concerns.

The medication room was clean, tidy and secure. Controlled drugs were stored in locked cupboards and medications were stored per resident. Trolleys are secured in a locked medication room and trolleys are secured to the wall.
Fire exits were free from obstruction, signage was clear and fire extinguishers were seen around the home. Staff are identifiable by both ID badges and uniforms. The premises is well kept both internally and externally. Access to the home is secure and passcodes on keypads are used for access between ground and first floor. Staff were observed using moving and handling equipment, ensuring to obtain direct consent from the residents prior to use. They communicated the process to the residents, patiently waiting for their response and interpreting their cues.

The home is designed to be dementia friendly. It is not a specialised dementia care facility, yet it features various color-coded handrails, bedroom doors and bathroom signage. The upper floor includes themed areas such as a beach themed ice cream area and a 'chatty bench'. The home is collaborating with our Community Link Worker to enhance its surroundings for individuals living with dementia. They have finalised and submitted documentation for the Local Authority's dementia-friendly guide, which is set for an annual review.

The medication policy is established and current, incorporating both home remedies and covert medications. Staff competencies are fulfilled in accordance with the Stockton Borough Council contract, occurring at least every six months. Evidence is documented in the care plan of the provider, which supports the resident in receiving annual health checks and medication reviews.

The home utilises electronic medication administration records. Administration records were observed to be complete, with no gaps; if any gaps occur, the electronic system alerts the staff. The manager conducts regular audits, which include checks of Medication Administration Records and controlled drug counts. Comments and actions taken are documented appropriately.

The staff files were examined and found to include the necessary employment verifications, such as Disclosure and Barring service certification with renewals occurring every three years and an annual declaration is submitted each year. It was noted that references had not been verbally verified; this matter was discussed with the manager, and it will be addressed moving forward. Residents were observed to be engaged in the recruitment process; one staff member's file contained a set of interview notes indicating that a resident participated in the interview. However, there were no recorded comments from the resident to convey their thoughts and feelings regarding the interview.

The online training and development system has a number of pre-set induction programmes dependent on the role the person is undertaking. The initial induction for care assistants includes the care certificate. Induction programme content includes policies and procedures and a mixture of face-to-face courses and eLearning.

A supervision matrix has been established that identifies when an individual is on probation, undergoing induction into their role or on maternity leave. Dates for supervisions are noted to have a specified due date. Staff members are observed to receive supervision on a bi-monthly basis. Appraisals are conducted on an annual basis.
 

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan for all questions assessed as 'Requires Improvement' and the Quality Assurance and Compliance (QuAC) Officer will monitor this for progress 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 relationship with the QuAC Officer and responds to requests for information in a timely manner. 

Engagement and Support from Transformation Managers

Millbeck's manager and wider staff team engage with the Transformation Team with regard to provider forums, activities, training, and communicate regularly with the team. The Transformation Team will continue to work with the manager to start looking at further opportunities, such as participation in care home research and other projects, pilots and initiatives.

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

Date of inspection

13 December 2018

Overall rating

Good