Mandale House - 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

17 and 18 November 2025

Date assessment was published

23 December 2025

Date previous assessment was published

27 February 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

The Home uses an electronic care planning system, with management completing the initial care plan based on information gathered during a thorough pre‑admission assessment. The care plans reviewed included detailed front pages containing a concise overview, key risks, a medical summary, essential contacts, and information regarding Power of Attorney (POA) and Do Not Attempt Resuscitation (DNAR) decisions. The documentation was consistent throughout, and there was clear evidence of regular reviews being undertaken to ensure that each care plan accurately reflects the Resident's current needs, abilities, and preferences.

Care plans reference the Deprivation of Liberty Safeguards (DoLS) and the Resident's capacity. Each DoLS care plan includes the application and expiry dates, The DoLS status is clearly displayed on the main homepage. Some Mental Capacity assessments were included within the care plan, but these need to be in place for more areas of care delivery and least restrictive options should be evidenced.

Residents who were spoken with reported feeling well supported, treated fairly, and respected by all staff. This was consistent with observations, which showed staff interacting respectfully, addressing individuals according to their preferences, and seeking consent before conducting any task. Staff were also consistently observed knocking on Resident's doors and waiting for a response before entering.

Residents are offered three main meals each day and were observed to receive a balanced and nutritious diet. Morning and afternoon snack trolleys are available, providing 

a wide selection of drinks and snacks, including tea, coffee, juice, cakes, biscuits, and fresh fruit. Residents were asked about their preferred mealtime locations, and staff supported and accommodated their choices. The Home had its last food hygiene inspection 11 February 2025 and received a five-star (Very Good) rating.

Residents spoken with confirmed they felt satisfied with the support they received around medication and felt sufficiently involved with decisions made. Staff were observed asking Residents if they required PRN (as needed) medication and clearly knew how they preferred to take their medication. Staff administering hold the level 3 qualification in medication and receive regular training updates around medication. Twice yearly medication competencies are conducted together with an annual topical competency.

Staff spoken with confirmed that they are confident in managing medication because of the training and support they receive.

Staff spoken with confirmed that they receive regular supervision sessions and an annual appraisal. Staff said that supervisions were supportive and gave them the opportunity to discuss areas of improvement and career progression. A staff training matrix is maintained to show all mandatory and specialist training for staff when this training was completed and when updates are required. Training is a mixture of on-line courses, workbooks, and face to face training sessions. The Home uses an online training platform " Your Hippo" overall compliance for mandatory training at the time of the assessment was 96%.

The atmosphere was seen to be appropriate for those Residents living with dementia, with orientation points throughout the unit. The Home was awarded a dementia friendly certificate on the 12 of May 2025.

Monthly audits are completed by the Manager in accordance with the annual schedule and appear to be thorough and effective. The Quality Assurance process is further strengthened by additional audits conducted during visits from the Regional Manager and Quality Assurance Manager. All service-related documentation and safety checks are stored in a dedicated file, which includes a summary sheet highlighting certificate renewal dates. Compliance is monitored by the Manager through routine Health and Safety audits. All required certificates were available and up to date.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address the areas identified as 'Requires Improvement' to ensure full compliance and improve quality. Progress towards meeting the action plan will be monitored by the Quality Assurance & Compliance (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 has a positive relationship with the QuAC Officer, maintaining honest and open communications and responding to requests for information in a timely manner.

Engagement and Support from Transformation Managers

The care home engages to a high level with initiatives, opportunities, and training from the Transformation Team. The manager has completed the Well Led Programme, and the home attends the Provider Forums, leadership networks, activity coordinator networks and engages with training opportunities, workshops, and research in care homes projects.

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

Date of inspection

31 July 2025

Overall rating

Requires Improvement