Millbeck 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 2026 to March 2027.

Date of inspection

11 to 13 May 2026

Date assessment was published

3 June 2026

Date previous assessment was published

21 July 2026

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

The home utilises an electronic care planning system. Care plans reviewed were personalised and comprehensive, with each resident having a front-page summary containing key information such as photograph, room number, resuscitation status, and the status of Deprivation of Liberty Safeguards or Liberty Protection Safeguards authorisations. This provided a clear overview of identified risks, medical history, care needs, and key contacts, supporting accessibility for professionals and families.

An "About Me" section was in place for each resident, detailing personal preferences, communication needs, and important relationships, promoting person-centred care. Care delivery was recorded in real time, with task completion monitored through a colour-coded system, enabling effective oversight. Minor instances of copied information were identified but were addressed and rectified during the assessment.

Daily records and monitoring charts were consistently completed, providing assurance that risks to health and wellbeing were effectively monitored. Recognised tools, including the Malnutrition Universal Screening Tool and Waterlow assessments, were used to assess and manage risks relating to nutrition, hydration, and skin integrity. Clear escalation processes were documented within care plans.

Monitoring systems covered key areas such as nutrition, mobility, continence, and personal care, supporting timely identification of emerging risks. Whilst care plans and risk assessments were reviewed monthly, some delays in updating the main body of care plans following changes were identified; these were addressed at the time of the visit.

Observed practice confirmed that care was delivered in a respectful, dignified, and person-centred manner. Residents were supported calmly and appropriately, with privacy maintained. Food and drink were offered regularly, with residents supported to make informed choices.

Staff demonstrated a good understanding of safeguarding, including types of abuse and reporting processes. They confirmed that concerns would be escalated promptly internally and externally, including to the local authority and the Care Quality Commission where required. Awareness of whistleblowing procedures and protections was evident.

Staff files evidenced appropriate pre-employment checks, including Disclosure and Barring Service checks, with systems in place to monitor renewals. Induction programmes, including completion of the Care Certificate for care staff, were structured and supported through a blend of electronic learning and face-to-face training.

A supervision matrix was in place, demonstrating that staff received supervision in line with contractual requirements, alongside annual appraisals. Training systems supported ongoing development and role-specific competencies.

Medication practices were safe and well managed. The medication room was secure, clean, and appropriately organised, with controlled drugs stored correctly. Daily temperature checks were completed with clear guidance in place for managing any variations outside of recommended ranges.

The service uses an electronic medication administration record system, with robust processes for medication receipt, verification, administration, and monitoring. Protocols for medicines to be taken as required and for variable dose medications were in place and up to date. Medication competencies were completed at least every six months in line with contractual requirements.

Good standards of food, hand, and personal hygiene were observed, with staff wearing appropriate personal protective equipment and following effective hand hygiene practices. Food was appropriately covered during transit, and dining tables were prepared in advance of mealtimes. The home holds a food hygiene rating of five, providing further assurance regarding food safety standards.

The home has been designed to be dementia friendly. Although it is not a specialist dementia service, features such as colour-coded handrails, bedroom doors, and bathroom signage support orientation and promote independence. The upper floor incorporates themed spaces, including a beach-themed area and a dedicated 'chatty bench,' which encourage social interaction and engagement.

The service is working to further enhance the environment for people living with dementia. Documentation has been completed for inclusion within the local authority's dementia-friendly guide, and the service has received an award in recognition of this work.

The premises were well maintained, clean, and secure, with appropriate access controls in place. Fire safety measures were observed to be robust, with clear signage and unobstructed exits.

Equipment was well maintained, with up-to-date servicing records, including six-monthly lifting equipment inspections and routine maintenance checks. All observed equipment was clean and appropriately labelled.

A comprehensive audit programme was in place, covering key areas such as care planning, medication, nutrition, falls, infection prevention and control, and Deprivation of Liberty Safeguards. Audit findings informed a live universal action plan, supporting continuous improvement.

The event recording system was used effectively to record accidents, incidents, complaints, and safeguarding concerns, with clear allocation of actions and oversight from senior management to ensure completion and accountability.

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, minor concerns - standard monitoring

Level of Engagement with the Authority

The provider has a good relationship with the Quality Assurance and Compliance (QuAC) Officer and responds to requests for information in a timely manner.

Engagement and Support from Transformation Managers

The management team at Millbeck demonstrate a professional and cooperative approach in their interactions with the Transformation Team, responding helpfully to communication and maintaining a positive dialogue. The manager took part in an early cohort of the Well Led Programme, as did the deputy. Whilst overall engagement is limited, there is a good opportunity to develop a more active partnership moving forward.

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

Date of inspection

13 December 2018

Overall rating

Good