Green Lodge - 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

6 to 8 October 2025

Date assessment was published

13 October 2025

Date previous assessment was published

22 August 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans viewed were of a good standard. Individual care plans were personalised to the resident and had evidence including resident preferences in how they wish to be cared for. There was only one example found of information being conflicting and no examples of incorrect names used. Front pages were detailed with risks to be aware of, what the resident may like to talk about, a medical summary, equipment requirements and key contacts. Care plans were seen to be reviewed monthly and there was also evidence of care plans being updated more frequently as needs and preferences changed.

Residents were treated with dignity, respect and kindness. Generally, staff were able to communicate well with those who are non-verbal or had limited communication and staff were seen to be encouraging, polite and patient. There are lots of displays around the home which are colourful and engaging, but these are not always in accessible formats. Pictorial paperwork was seen, such as menus and activity timetables. A Resident's Guide was viewed; it is not currently in an easy read format though is under review. The home is beginning to tailor to being dementia friendly as they undergo the Dementia Friend's accreditation, with most spaces having dementia friendly signage.

Care plans, risk assessments and best interest decisions are reviewed monthly. Reviews were personalised, though tended to be generic and some were repetitive. Most reviews seen were a recap of the care plan explaining care needs as opposed to a review of the month, concerns, incidents or anything needing monitoring for the next review. Evidence of involving residents and families in this was limited, Resident of the Day meetings were used and completed though again did not always offer a lot of detail.

Daily charts were completed frequently and reflected the needs of the residents. Notes were mostly recorded with details, such as food and fluid amounts offered and taken, but this was not always consistently used. The new manager has implemented a weekly weight tracking system for staff to colour code and record paper-based weight tracking to ensure they are correctly monitoring and identifying weight changes.

A varied activities timetable is on offer and observed as attended well, with some good examples witnessed of full lounges where residents were encouraging each other to take part despite differing abilities. Residents afterwards told of how they had enjoyed the activity and like how sociable they are in the home. Food choices were varied. Snacks and drinks are available to residents in communal areas, with choices of juice, water, biscuits, fruit and crisps. A tea trolley also moves around the home regularly. Those spoken with said they felt safe and looked after at the home, that the home helps them, they like the food and activities and spoke highly of staff.

All staff could recall having training on the Mental Capacity Act, Deprivation of Liberty and Safeguarding. Staff knew of the appropriate methods of reporting concerns if they had them, staff referred to the whistleblowing policy and knew where this was located.

Cleanliness practices around the home were to a good standard. Bathrooms were all clean, with 'I am clean' labels in use. There were good supplies of personal protective equipment and hand sanitisers. All staff were observed bare below the elbow with hair tied back. Food hygiene practices were also to a good standard, food was covered when in transit and all food was labelled with the date. The home had their latest Food Standards Agency Inspection on 20 August 2025 attaining a rating of 5 out of 5. The premises were safe and secured. High risk rooms were locked when not in use and stairwells and exits were key coded and alarmed. The home was clean, tidy and fresh smelling, though would benefit from some cosmetic upgrades, particularly in communal spaces. A few items for repair were noticed and the manager had acted on this swiftly.

Medication rooms were clean and tidy, locked when not in use and medication trolleys were attached to the wall in the rooms. Medications in the trolley are clearly labelled and included date of opening. Controlled Drugs are stored appropriately, with a double signed stock count in place and audits. Fridge temperatures are taken daily and this is reported to management for oversight. All medications were on the Medication Administration Record (MAR) except one which was a recent addition and not yet uploaded. There were a few instances of labels not matching MAR charts and the home are working with staff to ensure that this is checked and recorded correctly. Protocols are in place for medications taken as and when required. A range of manager oversight and audits are in place daily and monthly. Medication competencies are completed 6 monthly in line with the Stockton-on-Tees Borough Council's contract.

Staff files were completed to a good standard and evidenced safe recruitment practices. All staff had appropriate levels of identification, right to work and Disclosure and Barring Service checks. References were verified and employment history checks were completed on any gaps. Induction paperwork was viewed; all staff complete a comprehensive induction which was evidenced to be tailored to their specific job role. All staff new to care complete the skills for care certificate as part of their induction. Training certificates were on file. Training completion at time of assessment was at 97% overall.

Supervisions were completed regularly and had made considerable improvements, though these did not adhere to the Stockton-on-Tees Borough Council's contract as these are currently completed quarterly per provider's policy rather than bi-monthly. All staff were in the process of receiving their annual appraisal at the time of assessment. The previous year's appraisals for all staff were on file.

Monthly meetings take place for residents and their families and staff with meeting minutes recorded and shared. Residents said that staff are supportive when they have problems and help to solve them. Staff spoken with felt that they could report to the managers if they had concerns and that they have an open-door policy. Annual surveys are taken by head office.

A range of health and safety certifications were in place and in date. The home utilises an online portal for auditing, which is used by each department and management. Daily, weekly and monthly audits take place and management receives notifications of audits being completed in real-time. The new manager has implemented a situation report to compile all actions from the electronic system, in addition to any internal or external inspections, into a working action plan document which is shared and discussed with the regional manager, annotated and filed, to track continuous improvements.

Plans and Actions to Address Concerns and Improve Quality and Compliance

An action plan is to be created by the provider to address areas of improvement. This will be reviewed by the Quality Assurance and Compliance (QuAC) Officer with contract visits.

Level of Quality Assurance and Contract Compliance Monitoring

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 responds timely to emails and submissions. All levels of management communicate well with the QuAC team and provide regular updates, when needed, on the home's ongoing improvement plans.

Engagement and Support from Transformation Managers

Green Lodge engage with the Transformation Team initiatives, with the leadership team having completed the last cohort of the Well Led Programme, and the activity coordinator accessing the activities network, and events in the community. The Transformation Team will work with the home to identify new opportunities and leadership support.

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

Date of inspection

29 September 2020

Overall rating

Good