Primrose Court Nursing 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 2026 to March 2027.

Date of inspection

8 and 9 June 2026

Date assessment was published

23 June 2026

Date previous assessment was published

17 September 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Care plans were person-centred, personal to the resident, and completed to a good standard. Residents were seen to be supported in a person-centred manner with dignity upheld. Consent was obtained and choices respected when supporting individuals. Those spoken with commented on how familiar staff are with individuals and their care needs and this was reflected upon observation and interactions between staff and residents was positive and residents were well presented.

Staff had excellent knowledge of the Mental Capacity Act and how it impacted their residents. They were aware of which individuals had Deprivation of Liberty Safeguards (DoLS) and any associated conditions and were able to confidently discuss these in detail including reference to Herbet Protocols, Emergency Health Care Plan (EHCP) and Do Not Attempt CPR (DNACPR) documentation.

Documentation of keyworkers and their involvement in care planning and monthly reviews was inconsistent and people were not always aware of their allocations. Information gathered within assessments was included in care plans and escalation of concerns to other professionals, for example; health, was evidenced. People were involved in their or their loved one's care planning and kept up to date with any changes or relevant information. Feedback from residents, relatives, and professionals was positive, highlighting good care, communication,and appropriate escalation of needs. The keyworker system was in place but requires clearer communication and consistency in practice. Assessments, risk management and monthly care plan reviews were up to date,and of good quality. Daily notes were written factually and respectfully and aligned with care plans.

Residents were offered choice in daily living, including meals and high standards of food hygiene were observed. The home was rated 5 (very good) at their most recent food hygiene inspection in February 2025.

A range of quality assurance processes are in place to support governance and continuous improvement. Surveys for residents, relatives, staff, and professionals are aligned to the Care Quality Commission (CQC) domains, with evidence of analysis and responsive action planning. Monthly accident and incident reviews include trend analysis, lessons learned, and time-bound action plans, while safeguarding records are well maintained with clear logs, outcomes, and associated documentation. Complaints and compliments; management also captures compliments from residents and relatives. A comprehensive programme of audits is in place, led by the manager, covering key areas such as health and safety, nutrition and environment, with findings linked to action plans. Additional oversight is demonstrated through enhanced provider audits, ensuring thorough monitoring and accountability across the service.

Feedback from residents and relatives confirmed that they feel safe, well cared for and supported, including during safeguarding processes. Staff demonstrated strong knowledge of safeguarding procedures, including recognising abuse and escalating concerns appropriately. The home environment was clean, well-maintained and supported by effective infection prevention and control processes, with regular audits and clear oversight and several designated infection control champions. Medication management was generally safe and well organised, with appropriate storage, auditing, and staff competency checks in place. The service provides a well-equipped, dementia-friendly environment that promotes independence, supported by comprehensive health and safety systems, regular maintenance checks, equipment servicing, and up-to-date policies. The home has completed the dementia friendly guide, as per contractual requirement. Overall, robust governance arrangements are in place, with minor improvements identified to strengthen recording and audit follow-through.

Regular supervisions and appraisals take place in compliance with the required bimonthly supervision and annual appraisal schedules. Staff files were well organised and contained all necessary recruitment documentation, including verified references, Disclosure and Barring Service (DBS) checks with 3 yearly updates (per good practice recommendations), with evidence of internal auditing. Induction processes incorporated mandatory training, including completion of the Care Certificate and were properly documented and signed off. Training compliance was recorded at 100%

Staffing levels exceeded dependency tool requirements, with appropriate skill mix evidenced across rotas, which are effectively managed through an online system. Workforce stability was supported by internal cover for shifts and ongoing professional development opportunities, alongside designated staff champions in several key care areas.

Plans and Actions to Address Concerns and Improve Quality and Compliance

The provider will complete an action plan to address the recommendations made and one area rated as 'Requires Improvement' and this will be overseen for compliance by the Quality Assurance & Compliance Officer (QuAC).

Level of Quality Assurance and Contract Compliance Monitoring

Level 1 - No concerns - standard monitoring

Level of Engagement with the Authority

The provider is responsive to requests from the Local Authority and liaises closely with their Quality Assurance and Compliance (QuAC) Officer. Performance Dashboard submissions are made in a timely manner and queries are responded to promptly.

Engagement and Support from Transformation Managers

Engagement between the Transformation Team and the care home remains positive, with the home actively involved in key initiatives and development opportunities. This includes consistent attendance at provider forums, activity networks, workshops and training, supporting ongoing learning and service enhancement. The manager is planning to join the Council's 'Well Led' leadership development programme, further evidencing their commitment to strengthening leadership and embedding a culture of continuous improvement.

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

Date of inspection

4 July 2023

Overall rating

Good