The Poplars Care Home - 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 2024 to March 2025.

Date of inspection

12 November 2025

Date assessment was published

3 December 2025

Date previous assessment was published

30 January 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

There has been a change in management since the last assessment, the current manager has been in post approximately 6 months.

The home uses an electronic care planning system. Care plans were found to be person centred and included personal and pertinent details and other important information such as risks to be aware of, information you should know, equipment needed, a medical and care summary along with key contact information such as family members, social worker and GP.

Mental Capacity assessments were seen to be in place and Deprivation of Liberty (Dol) Authorisations for those residents who were deemed to lack capacity, with details such as expiry date and date to renew recorded in relevant care plans. Documentation was seen to be in place for any advanced decisions such as Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Emergency Hospital Care Plans (EHCP) with detail recorded in care plans and on residents' profiles.

All residents have allocated key workers as per our contractual requirement.

Resident and family members and representatives are provided with a service user guide on admission to the home which contains details of how to raise concerns and, or make a complaint and further information was observed to be on display in the home. Evidence was seen of resident, family and representative involvement in care plans and reviews.

Care plans were seen to promote independence detailing what residents could do for themselves and what they require support with.

Appropriate assessments are used to ensure residents needs are met and their welfare protected such as Malnutrition Universal Screening Tool (MUST), Waterlow, pain, continence, dependency, falls, mobility, Personal Emergency Evacuation Plans (PEEP) etc.  

All care plans and assessments are reviewed at least monthly. Daily notes contained a good level of details.

Care plans were seen to include dietary requirements or restrictions, although some likes and dislike recorded information was quite limited.

Feedback from residents spoken to was positive advised they felt safe and were well looked after. Residents provided positive feedback regarding the activities and food in the home.

Staff had the required knowledge and confirmed the received sufficient training for the job role. Staff rotas were reviewed against the dependency tool and evidenced sufficient staffing however a visiting family member advised they did not feel there was enough staff available in the home. During the assessment staff were generally seen to be visible throughout the home, however there were times when staff were observed in the lounge with residents, due to the layout of the home reducing staff visibility for residents.

Safer recruitment practises are followed within the home, on commencement of employment all staff received an induction, mandatory training and competency assessments. Training was seen to be monitored and refreshed regularly, at the time of the assessment training compliance was 94%. Regular supervision is in place for staff however annual appraisal were overdue, the manager was aware of this and had plans in place to complete.

At the time of the assessment, substantial work was underway on replacing a number of doors and door frames as required due to fire regulations, the home was under an Enforcement Notice, this has been reviewed and reduced to an action plan. The home was observed to be clean and tidy however due to the repairs required redecoration, the manager has identified a number of improvements they would like to make.

The home is split over 2 floors and part of the top floor is a dementia unit with key coded access. Appropriate dementia signage was seen to be in place on some toilets and bathrooms but not on others. The manager is currently working towards the dementia care home guide.

Some issues were observed in bathrooms, one bathroom had equipment stored in it preventing use, a shower chair was seen to be rusting these were raised with the manager to address.

Appropriate waste disposal arrangements were in place, foot operated bin not seen to be overflowing. Bedrooms were seen to be personalised.

Areas which posed a risk to residents such as laundry, kitchen, sluice were seen to have appropriate key code restrictions in place. Control of Substances Hazardous to Health (COSHH) data sheets were in place. The most recent Food Standards inspection was 25 September 2024 and the home maintained the 5-star rating.

Infection control audits were carried out, the Infection, Prevention and Control (IPC) nurse has visited the home, and the manager is in the process of arranging a visit to undertake the Local Authority IPC Audit.

Staff were observed to administer medication in a safe and person-centred way and good hand hygiene followed. Medication was stored securely, room and fridge temperature checks in place however improvements were found in relation to medication records, handwritten Medication Administration Records (MAR) were missing details such as strength and special instructions, a PRN protocol viewed had not been reviewed within the required timescale.

The manager has a range of methods to gather information about the quality of services delivered such as comments and complaints, accidents and incidents recordings, audits, staff, resident or relative meetings audits, surveys, suggestions etc. The manager analyses feedback and creates an action plan for the negative comments received.

A range of monthly audits were seen to be in place such as Health and Safety Management, Food Hygiene practices, Fire Safety - Staff, Fire Safety - Environment, Care Plans, Service Use, Dignity, Medication, Kitchen and Dining and Domestic and Laundry. Further quality improvements and policy quarterly audits were in place. Actions identified in audits were transferred onto an action plan. 

Appropriate maintenance checks were seen to in place including fire system checks, water temperature checks etc. with management oversight.  

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address the areas identified for improvement to ensure full compliance and improve quality. Progress towards meeting the action plan will be monitored by the QuAC Officer.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns, minor concerns - standard monitoring

Level of Engagement with the Authority

The manager engages well with the QuAC Officer, is responsive to requests and submits performance information in a timely manner.

Engagement and Support from Transformation Managers

The manager at The Poplars is relatively new to the role but has demonstrated strong engagement and commitment. He regularly attends Care Home Provider Forums, actively collaborates with partners and stakeholders, and responds promptly to communication from the Transformation Team. Plans are in place for the Transformation Team to visit the home and provide an overview of the resources and support available in Stockton to strengthen the sector. The manager has been very receptive to this approach, and we look forward to building a positive and productive relationship with the home in the coming months.

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

Date of inspection

16 May 2023

Overall rating

Good