Reuben Manor - 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

4 to 6 August 2025

Date assessment was published

5 September 2025

Date previous assessment was published

14 August 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

At the time of the assessment the registered manager was on long term absence from work.

On the whole care plans were seen to be person centred containing pertinent details however there was some evidence seen of copying and pasting, which resulted in two care plans containing incorrect names. Care plans detailed what people can do on good and bad days and detailed where an individual would require encouragement and support to maintain independence or to engage in care tasks. Care plans evidenced involvement with the resident and representatives in pre assessment documentation and reviews.

Assessments and risk assessments were mostly seen to be in place though improvement is required to ensure welfare is protected. All residents were seen to have a Personal Emergency Evacuation Plan (PEEP), however there had not been consideration given to assessments and care planning to ensure that a resident who regularly leaves the home continues to safely receive the care and support required and the care plan for a resident who has a modified diet did not contain adequate detail and was contradictory to the information displayed on the landing page of the electronic system.

Assessments and care plans were seen to have been reviewed monthly and where a change in need occurred.

Staff were observed to support residents in a non-discriminatory manner, promoting dignity and respect by asking for consent before providing care and support, knocking on bedroom doors before entering, using people's names when talking to them, offering choices and so on.

Families were observed to visit the home during the assessment, families and friends are supported to take residents out of the home to access the community. Pets were also seen to be welcomed into the home. The home has a number of communal areas in which families can access when visiting their loved ones including a coffee shop. The home has a toy box and equipment to support families visiting with young children. The service user guide referenced family being able to visit at any time and also have meals with their family member.

The home also provides Dementia training for families, with dates available on a monthly basis. The home also has volunteers to spend time with residents and support activities. The home was also in the process of working with local voluntary agency to organise an event to set up information stalls for residents and families.

The home has two activity co-ordinators. The home produces a week activity booklet that is provided to residents and available in communal areas. The activity booklet includes details of the activities planned for the week, with at least two activities per day, morning and afternoon and also two options of activities. Activities for the week of assessment included a range of in house and community activities such as daily news and catch up, quiz, pub visit, bingo, music therapy, chaplain visit, church service, sew n so, sign along, church friendship group and coffee morning, love to move. The activity booklet also contains puzzles and quizzes for residents to complete if they wish. The activity plans for the day were available in a number of areas of the home, that is. each floor, unit and foyer area which provides information to visiting family and friends. Activity information was available on display stands in text format. The activity booklet contained images and pictures that supported the activity.

The home encourages and supports residents to provide feedback in a number of ways such as resident meetings, resident surveys, suggestion boxes are available on each unit and on the reception desk. The most recent residents survey showed an overall satisfaction score of 92% for residents and 89% for family and friends. A poster was also displayed advising the home had score of 9.8 out of 10 for the reviews in July.

Safer recruitment practice was seen to be in place for the homes staff, with all staff files seen to contain application forms, interview notes, references with evidence of verbal verification checks, right to work and Disclosure and Barring Services (DBS) certification with barred list check. DBS risk assessments were seen to be in place where required for positive DBS checks and Disclosure and Barring Certificates are renewed every 3 years.

Appropriate checks were in place for visiting professionals such as hairdresser and podiatrist.

The home uses two agency staff to cover staff shortages in the home when required, although an agency file was in place which contained agency profile, induction and any competency assessments. Agency profiles were seen to contain DBS certificate date and certificate number, one of the agency profiles contained the level of DBS and if Barred list check was included however the other didn't. One of the agency staff files viewed did not have the profile from the agency. There was no evidence of home having undertaken their own due diligence for example obtaining a copy of the DBS certificate or Right to Work check.

Staff confirmed they received appropriate induction at the start of their employment and received regular training, supervision and annual appraisal. However the frequency of supervision and appraisal were found to not be in line with contractual requirements. At the time of the assessment staffs overall training compliance was 86%.

Staff administering medication confirmed they were qualified to Level 3 and received 6 monthly medication competency assessments, as contractually required.

The home environment was seen to be clean and tidy. The décor of the home and furniture of a good standard. The dementia unit was dementia friendly including appropriate signage for bathrooms, memory boxes outside of bedrooms, coloured toilet seats, coloured crockery, sensory area and activity room. Bathrooms were clean and tidy and free from any products. Laundry room was seen to be well organised, with different basket for each room. Appropriate industrial equipment was in place. Laundry and kitchen areas were key coded to prevent authorised access. The kitchen was last inspected 9 April 2025 maintained its 5 start food hygiene rating. Local Authority Annual Infection Protection Control (IPC) Audit was seen to be complete and shared with Infection Protection Control nurse; audit feedback was 100%. The home has not yet completed the Dementia Care Home Guide however has a Dementia lead within the company and a dementia friendly approach with use of contrasting colours and wellbeing related items throughout, including memory boxes displayed outside of bedrooms.

The medication room was clean and tidy and secure. Controlled drugs were stored in separate controlled drug cupboards. On the whole, room and fridge temperatures were seen to be recorded daily, however a few days were missing.

A Medicines Management Policy is in place, in date and was seen to contain information relating to covert medication and homely remedies. Staff medication competency assessments were in place in line with contractual requirements. Front covers were seen to be in place for Medication Administration Record (MAR) Charts with photographs, allergy status and how to the resident likes to take their medication. MAR charts were seen contain all prescribed medication and reference other records such as Topical Medication Administration Record (TMAR). Instructions on MAR Charts were seen to match pharmacy labels and on the whole MAR Charts were seen to be double signed however one resident's MAR Chart viewed only had one signature. Pro re nata (PRN) Protocols were seen to be in place. Regular managers audit on Controlled drugs. The medication management contributed towards the decline from Excellent to Requires Improvement in the Safeguarding and Safety Domain.

Although the home has a range of risk assessments in place, control measures were found not to be followed, for example a heated roller grill did not contain any warning signage, cleaning products accessible unlocked cupboard and maintenance equipment left unattended in a corridor. Some service certification documentation was also found to be out of date. This contributed towards the decline from Excellent to Requires Improvement in the Safeguarding and Safety Domain.

The home undertakes a range of audits with an audit schedule in place; most audits were seen to be completed at the required frequency however some gaps were found.

Records were found not to be held securely, during the assessment all 3 nurse stations were found to be unlocked and unattended, with 1 having an open laptop logged onto the electronic care plan system, and all having open or unlocked cabinets which contained confidential information, for example Do Not Attempt Resuscitation.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address all individual questions identified as Requiring Improvement, the action plan 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 - 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

Although Reuben Manor have low engagement with the Transformation Team, the leadership team in the home do acknowledge emails and calls and respond when necessary. The Activity Coordinator attends the activity networks, has been involved in previous training and workshops and also brings residents to events in the community. The Transformation Team will continue to link in with the care home around opportunities and initiatives to improve engagement from the care home manager and deputy. 

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

Date of inspection

15 December 2020

Overall rating

Good