Ayresome Court - 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

27 to 29 May 2025

Date assessment was published

18 July 2025

Date previous assessment was published

26 June 2024

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans viewed were seen to be person centred with very good detail on the residents likes, dislikes and preferences. There were very good instructions given on how to care for the resident, how they like things to be done and behaviours they may or may not present depending on their feelings. Resident preferred names were used throughout. Resident of the Day meetings are used every month to engage residents and their families in their care planning, with a champion in place to ensure this is completed. All paperwork is in accessible formats and pictorial signage is used around the home.

Residents spoke very highly of the staff who support them and are very happy and appreciative of the care team. Observations saw staff encouraging residents to be independent and promoting choices. Staff were observed patiently allowing time for residents to respond. All staff have completed the Dementia Friends accreditation and have utilised resources well. Residents confirmed feedback is sought routinely. Activity and mealtime feedback is taken, surveys are completed annually and resident meetings are scheduled bi-monthly.

There is a varied activities calendar each month and one to one time for those who cannot or choose not to leave their room is also considered. Families and friends visited frequently and were also observed joining in with mealtimes and activities. Families have recently taken part in Dementia Friends training with staff. All the above points contributed to the 'Excellent' rating in the Involvement and Information domain.

Care plans had good evidence throughout of how independent each resident is, what they are and are not able to do for themselves for each task, and how to support and encourage residents to remain independent was also detailed. Care plans are reviewed monthly and those viewed were seen to be reviewed timely with evidence of updates made when needed. Keyworkers are clearly identified and consideration for keyworker allocations include relationships built between residents and staff.

Daily notes, handover logs and personal care logs all made note of consent. Daily notes and handover logs for support given also encouraged staff to log levels of independence. Daily notes and handover logs were seen to be completed timely and daily, though staff did not always utilise the free type fields to add information additional to the pre-populated dropdown fields, to allow for more consistent and personalised notes.

Staff were confident in both Deprivation of Liberty and Mental Capacity Act and could explain how these impact on care delivery. Staff were fully able to explain safeguarding and whistleblowing practices. Observations in relation to Infection Prevention Control practices were of a very high standard and all staff seen were bare below the elbow. Health and Safety certification and audits were all in date at the time of assessment. Home and environment risk assessments were in place and reviewed monthly.

The medication room and nurses' station were clean and tidy; both the medication trolley and room were locked and secured appropriately. Medication rounds were good, with both Nurses and Seniors knowing residents and their medications well. Rounds were carried out in a safe and person-centred manner with good hand and trolley hygiene practices observed. Medication Administration Records were completed to a good standard. Staff were found to be appropriately trained. Staff competencies were completed in line with contractual requirements.

Safer recruitment practices were evidenced, all staff files included signed copies of job descriptions and contracts of employment and completed comprehensive inductions in line with skills for care and the Care Certificate. Training completion was at 99 per cent at the time of assessment and this was a mix of face to face and online learning. At the time of assessment some supervisions and appraisals from the previous year were not available, though the manager had brought these back in line with contractual requirements.

The manager keeps a clear and concise filing system of audits, incident logs and service certifications. Staff meetings take place bi-monthly. Meeting feedback forms are collected following each meeting for feedback on how supportive and inclusive meetings were. Staff feedback on management was good and they reported feeling supported. Staff said they wouldn't feel nervous to raise concerns as this is encouraged. Resident and family feedback was also positive, no residents spoken with had raised a complaint previously, but spoke of the manager visiting them frequently to check-in.

Plans and Actions to Address Concerns and Improve Quality and Compliance

An action plan is to be created by the provider to address the one area of improvement found. This will be monitored by the Quality Assurance and Compliance (QuAC) Officer for compliance.

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 level of engagement with the Local Authority, responsive to both QuAC and Transformation teams and engages well with forums, initiatives, and training that is offered. Monthly reporting is submitted timely.

Engagement and Support from Transformation Managers

Ayresome Court engage regularly and positively with the Transformation Team - attending Provider Forums, peer meetings, training and workshops. The Activities team are involved in the Activity Coordinator Network and staff bring residents along to events and opportunities in the community. The care home has been involved in previous research studies and are engaging in current studies with local researchers in the Northeast. 

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

Date of inspection

26 February 2020

Overall rating

Good