Wellburn 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

12 and 13 January 2026

Date assessment was published

19 January 2026

Date previous assessment was published

17 February 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were well written, with lots of person-centred detail on needs and preferences. Care plans explained the independence level of residents, and how a good or bad day can change the level of support they may need. Observations demonstrated staff seek consent prior to providing care and support. Staff were observed to treat residents with dignity and respect, addressed residents by their name, and allowed time to make their choices. Residents' bedrooms were seen to be personalised to each resident. Staff offered choices and had a good understanding of resident's preferences and were also observed asking residents when they would like their care tasks completing.

Resident and family involvement in care plans was evidenced, and a good resident of the day meeting format is used to encourage feedback from residents each month. Staff were observed to seek feedback from residents informally, for example after finishing their meal. Feedback is also requested more formally through resident of the day which asks for feedback each month on staff, if their choices and wishes are respected, food and drink, the cleanliness of the home, activities, and any improvements they feel could be made.

A good activities programme is in place which included a range of in-house activities, entertainers, social clubs visit, sensory sessions, and church visits. Activities are in place seven days a week, both morning and afternoon. The activity co-ordinator also spends one-on-one time with residents to plan tailored activities to an individual's goals. The programme is displayed around the home in easy read though is also verbally explained to residents.

The home's current food hygiene rating is five, as of February 2025. Residents are offered a good variety of drinks, meals, and snacks. Observation of residents being asked, and asking for, food and drink outside of mealtimes was made in addition to the tea trolley regularly moving around the home. Hydration and snack stations are posted around the home. Residents spoken to confirmed they enjoyed the food and drinks available in the home. Staff were observed to give residents choices of meals and portion sizes.

Residents in the home stated they felt safe and well looked after. The home demonstrated a relaxed environment with positive and respectful interactions. All staff confirmed they received training around Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS), and Safeguarding. Staff were confidently able to explain how they implement this training into practice day to day. Staff knew of the correct steps to follow to report any concerns.

The home environment is welcoming, clean, and tidy, and free from malodour. Communal spaces were plentiful, well-lit, and well decorated. The home has completed the Dementia Friends accreditation and has begun to tailor their home to be more dementia friendly. A good standard of hygiene is followed, with good infection control practices being in place. Staff were all bare below the elbow, with hair tied back, and used personal protective equipment correctly. Good cleaning practices were observed. Toilets, bathrooms, and equipment were clean, free from rust, mildew, or product buildup. On walkaround the home was found to be safe. Doors to high-risk rooms, stairwells, and exits were locked. Key coded doors were around the building. Stairwells and fire exits were free from blockages. A range of appropriate service certification was in place and in date.

Medication rounds observed followed good hand hygiene and person-centred practices, staff had a good understanding of how residents like to take their medications. Medication rooms were clean, tidy, and appropriately secured. Medication trolleys were secured to the wall in the room and locked. Medications were clearly labelled, with dates of opening and expiries. Controlled drugs were stored in a locked cupboard; a countersigned count book was in place. Medication administration records (MAR) were completed accurately. Every resident had a good standard of front covers to their MAR. MAR charts reviewed had no gaps in recording, no overwriting or crossing out. Protocols were in place to a good standard for medications taken as and when required. The manager undertakes regular medication audits across all units within the home, and staff competencies take place six monthly, in line with Stockton-on-Tees Borough Council's (SBC) contract.

Safer recruitment practices are in place. Staff files were well organised and contained evidence of appropriate pre-employment checks. All staff had Disclosure and Barring Service (DBS) certificates. A comprehensive induction is completed by all new members of staff, completed alongside the Care Certificate for those new to care. All staff receive bi-monthly supervisions and an annual appraisal, meeting SBC contract requirements. All staff confirmed they felt there was enough staff on duty to meet the needs of the residents, and visibility of staff throughout the assessment was good.

Audits included management, maintenance, domestic and infection control, and kitchen. Daily logs and walkarounds are also in place. The home has a working 'home development plan' in place for any areas of improvement identified. A range of appropriate and in date service certification was seen and kept on file. A safeguarding log is in place to track safeguarding alerts. Regular resident surveys are taken with results compiled into a report to be displayed and shared. Regular staff meetings take place, with good attendance, and minutes are shared. Regular resident and family meetings take place, with a 'you said, we did' board on display for resident comments.

Plans and Actions to Address Concerns and Improve Quality and Compliance

No areas of improvement were identified in this assessment.

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns, minor concerns - standard monitoring

Level of Engagement with the Authority

Wellburn House have a good level of engagement with the Local Authority. The manager is receptive to both the Quality Assurance and Compliance and Transformation teams and responds timely to any requests. The manager is always on time with submissions.

Engagement and Support from Transformation Managers

Wellburn House engage well with opportunities and initiatives through the Transformation Team, including attending Provider Forums, Activity Coordinator networks, training, and events in the community. They collaborate with other care homes and residents across Stockton and are open to joined up working.

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

Date of inspection

4 April 2025

Overall rating

Good