Hadrian Park - 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

24 and 25 November 2025

Date assessment was published

4 December 2025

Date previous assessment was published

24 January 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were person-centred and included comprehensive details about each individual's life history and preferences. Pre assessment documentation was noted to have been accurately transposed into care plans, ensuring continuity of information. Needs-specific assessments are regularly reviewed, and the findings are integrated into care plans. Personal Emergency Evacuation Plans (PEEPs) are in place and maintained accurately. Monitoring forms and welfare checks are implemented where required, particularly following incidents such as falls, demonstrating an ongoing commitment to resident safety and wellbeing. Care and support plans are reviewed at least monthly and contain up-to-date information, and daily notes accurately reflect the individual's current presentation and interventions from external professionals. Person-centred care is reinforced through the "Resident of the Day" initiative.

Families and pets frequently visited, and residents were supported to access activities both inside and outside of the home. The home uses its Facebook page and the Relish app to share updates and personalised information with relatives, including newsletters and photographs of residents' daily activities. A diverse range of activities is offered daily, including arts and crafts, quizzes, pampering sessions, and outings. Residents' requests are accommodated where possible, such as a recent beach trip arranged in response to a wish tree request.

Observations during the assessment confirmed a culture of dignity, respect, and kindness throughout the home and resident engagement was actively promoted. Friendly conversations were frequently noted, reflective of the warm and supportive environment.

Residents were observed receiving food and beverages outside standard mealtimes, with snack trolleys and stations offering a variety of options including fortified juices, fresh fruit, and pastries. Domestic fridges and kettles are available in dining areas, providing residents with additional autonomy. The home maintained a calm atmosphere, and positive relationships between staff and residents were evident. The home was clean and tidy and received a "Very Good (5)" rating in its August 2025 food hygiene inspection.

Staff demonstrated clear knowledge of safeguarding principles, whistleblowing policies, and reporting procedures, including awareness of external agencies. A review of staff files confirmed that all essential employment checks, including DBS certification and right-to-work documentation, were completed and recorded. All staff complete a structured 12-week induction programme that includes shadowing and the completion of an induction booklet, followed by a probation review signed off by management. Training is aligned with Skills for Care standards (as per SBC contract), including the Care Certificate for new employees and refresher training for those holding NVQ3 qualifications. A supervision and appraisal matrix is in place, evidencing annual appraisals and bimonthly supervisions (as per SBC contract), with only a small number of missing entries.

Monthly eMAR checklists and medication audits showed compliance scores of 76% in September and 71% in October. Additionally, the North of England Care Support (NECS) Medication Optimisation Team conducted a review in September 2025, resulting in a score of 75.5% and an associated action plan that is currently being implemented. MAR charts and patch application records were completed appropriately on the electronic system, though there were some issues around medication labels which required attention. Otherwise, medication was stored appropriately with clean and tidy medication rooms and trolleys. Controlled drugs were securely stored, and records were properly maintained. Room and fridge temperatures were consistently monitored and recorded within the required limits. Competency assessments are conducted every six months in line with contractual requirements. Three staff members involved in medication administration have not yet achieved the contractually required Level 3 medication qualification, and the manager is addressing this.

Safety and compliance measures were found to be satisfactory. Fire escapes and corridors were free from obstruction, and keypad security systems were in place where restricted entry was required. The Lifting Operations and Lifting Equipment Regs (LOLER) testing certificate was valid, and staff were seen using moving and handling equipment correctly, promoting dignity and respect throughout. Equipment servicing and maintenance checks were completed regularly and within the required timeframes, and were tracked via a new electronic system, which schedules checks at set intervals and provides compliance dashboards. Orientation points and signage are visible throughout. The home has a dementia friendly environment, particularly on the Chesters Suite where those with advanced dementia reside, and the Dementia Friendly Guide has been completed as per contract.

Quality assurance processes are robust, with feedback collected through multiple channels, including QR codes, surveys, and meetings. Actions taken are communicated via "You Said, We Did" boards and other documented formats. Monthly random audits are conducted alongside eight-weekly appraisals by the Care UK Quality Manager, and case studies are used to support learning. All incidents, accidents, near misses, and complaints are thoroughly investigated, with outcomes and lessons learned shared transparently.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The Provider will draft and complete a small action plan to address any recommendations made as well as the one area identified to require improvement and the QuAC Officer will monitor progress against this to ensure the expected standard has been achieved.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns, minor concerns - business as usual, standard monitoring

Level of Engagement with the Authority

The managers at Hadrian Park are responsive and engage well the QuAC officer.

Engagement and Support from Transformation Managers

Hadrian Park engage fully with the Transformation Team. Both the manager and the deputy have completed the Well Led Programme, as have some of the wider staff team. They attend all networking, provider forums, activity coordinator networks, research meetings and events and activities in the community. They work collaboratively with other care homes across Stockton.

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

Date of inspection

15 June 2023

Overall rating

Good