Highfield - 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

11 to 13 August 2025

Date assessment was published

1 September 2025

Date previous assessment was published

28 January 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

The home has recently transitioned to an electronic care planning system; consequently, the care plans are still a work in progress. However, the care plans that were reviewed appeared to be person-centred, containing concise information regarding the residents' likes, dislikes and preferences. Instructions were provided on how to care for each resident, detailing their preferred methods of care and the behaviours they may exhibit based on their emotional state. The names of the residents were consistently used, along with their preferred names.

Throughout the assessment, numerous positive examples of the relationships between residents and staff were noted, showcasing how residents were treated with dignity, respect, and kindness. Observations indicated that staff actively encouraged residents to maintain their independence. They always knocked before entering, whether doors were open or closed and were often heard introducing themselves and engaging in friendly conversations with residents. These observations affirm that the well-being of residents is a primary focus, with all individuals appearing to be well cared for.

The manager performs comprehensive audits and carefully documents every action in the Home Improvement Plan, all of which are finalised with signatures upon completion.

Recent fire safety checks have been conducted, encompassing fire alarms, heat detectors, emergency lighting and firefighting equipment. A fire risk assessment was completed in September 2024 and is due for review September 2025. There is documentation available for conducted fire drills.

To ensure all maintenance services and checks are organised, the manager keeps a detailed matrix. There is also evidence of Legionella risk assessments and water temperature checks. Maintenance audits for mattress inspections were seen to be recorded, along with checks for window restrictors.

The fire exits are kept clear and unobstructed, marked with clear signage, and fire extinguishers are conveniently located throughout the building. Staff can be easily identified by their identification badges and uniforms. The facility is well-kept, both inside and outside, and access is secured with passcodes.

During observation staff were observed using moving and handling equipment. They made sure to obtain direct consent from the residents before using it. Moreover, they communicated the process clearly with the residents, patiently waiting for their responses and interpreting their cues effectively.

The home incorporates dementia-friendly design features, such as coloured handrails, distinct bedroom doors, and clear bathroom signage. The manager is presently engaged in finalising the Stockton Dementia Friendly Care Home Guide and recognises that it is a component of the Local Authority contract.Throughout the assessment, numerous staff members were noted participating in the Local Authority Dementia Friends training, with an additional training date scheduled for the remaining staff.

The medication policy is established and current, incorporating both home remedies and covert medications. Staff competencies are fulfilled in accordance with the Stockton-on-Tess 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 Record (MAR) charts. All prescribed medications are listed on the MAR charts and are entered through the pharmacy. Upon receipt, the MARs are verified against medication labels, and a second staff member checks them, with both staff members signing or initialling the MAR chart. Administration records were observed to be complete, with no gaps. if any gaps occur, the electronic system alerts the staff.

The administration of Pro re nata (PRN, latin for 'when required') and variable dose medications is thoroughly documented, with protocols for PRN and variable doses being current and in place.

The manager conducts regular audits, which include checks of MAR and controlled drug counts. Comments and actions taken are documented appropriately.

The medication room is maintained in a clean, tidy, and secure condition. Controlled Drugs (CDS) are stored in locked cupboards. Medications are stored per resident.

Upon reviewing the staff files, it was confirmed that all essential employment checks, including Disclosure and Barring Service (DBS) certification, were duly completed. The files featured a wealth of information, including application forms detailing full employment histories, responses to interview questions, two written references, job descriptions, contracts of employment and staff health checks. Furthermore, there was clear evidence of each staff member's right to work in the UK. It was noted that references had not been verbally verified. This matter was discussed with the manager and it will be addressed moving forward.

New employees participate in an induction process that begins off-site and lasts for three or five days depending on job role. This is followed by an on-site induction period of 12 weeks. Throughout the induction all staff members are required to complete their training. After that, a shadowing period will occur before the employee transitions to working independently. Additionally, all mandatory training sessions must be completed.

It was confirmed that all staff have had a recent supervision. Additionally, every staff member received an appraisal within the past year.

Plans and Actions to Address Concerns and Improve Quality and Compliance

No areas were identified that were 'Requires Improvement.'

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No 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

The Transformation Team remain in regular contact with Highfield to keep them updated with training, networking, workshops, activities, research and other opportunities. The manager has engaged in the training opportunities and some networking, and aims to become more active with other initiatives, including the activity coordinator network. The Transformation Team will continue to engage with the leadership team at Highfield.

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

Date of inspection

9 October 2018

Overall rating

Good