Ayresome Court - 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

27 and 28 April 2026

Date assessment was published

28 May 2026

Date previous assessment was published

18 July 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

Daily notes and charts were completed consistently. There were minimal instances found of staff completing notes inconsistently. Monthly reviews had no identified gaps. Review notes gave good detail on the reasons for any changes, and additional reviews were seen outside of scheduled monthly reviews for additional updates when required. Each care plan had an associated risk assessment, and this was also reviewed monthly.

Residents all have an allocated keyworker, in line with the Stockton-on-Tees Borough Council (SBC) contract. Keyworkers are chosen based on relationships, with the resident and their family consulted, and are clearly recorded on care plans. Keyworkers were not always involved in building and review of care plans.

The food hygiene rating for the home is 5. Behaviours relating to food hygiene were of a good standard. Tables were set appropriately and food was covered in transit. Residents are supported to make choices from the menus daily, and the weekly menu is displayed on the dining room wall, with a copy in resident bedrooms. A trolley with refreshments moves around the home outside mealtimes.

Care delivery was observed to be safe and those spoken with confirmed the same level of care. Residents spoke highly of the staff caring for them. Safeguarding information is on display around the home. Staff knew the available reporting mechanisms for any concerns, both internal and external. Staff confirmed they had all completed safeguarding training and are aware of whistleblowing policy.

The internal environment is clean and tidy, furniture is secured, exits are alarmed, and corridors are clear from trip hazards. Appropriate Infection Prevention and Control (IPC) procedures were observed and followed by all staff. An IPC champion is in place as per SBC contract. Externally the premises are well maintained. Servicing and certificates are in place for equipment, including 6 monthly lifting equipment regulations testing. High risk rooms and areas are coded to prevent access; there were instances throughout the assessment of these spaces being left accessible.

Medication rounds observed were completed in a person-centred manner. Staff were very well informed of the resident needs and had a lovely warm rapport in each room visited. Good hand hygiene practices were followed, and medications were checked against the medication administration record before administering. The treatment and medication trolleys were locked, and the trolley was well organised. Medications were labelled clearly with dates of opening. Medications no longer in use are safely disposed. Controlled drugs were stored in a locked cupboard and had a count book in place, audited weekly. Ambient room and fridge temperatures were taken daily.

Medication administration records had front covers in place. Protocols for medications taken as and when required were in place. No gaps were witnessed on medication administration records and correct codes were used for administration, refusals, and non-administered. Medication competencies are undertaken six monthly, in line with the SBC contract. Regular medication audits are undertaken.

The provider undertakes safer recruitment checks. References, copies of right to work documents, and Disclosure and Barring Service certificates were in place. Induction booklets and probation reviews were on file. Review of competency and performance was evident. The induction content was thorough and covered the Care Certificate. Staff supervisions undertaken bimonthly with an annual appraisal in line with SBC contractual requirements. The dependency tool was viewed and evidenced that the home is always sufficiently staffed, with an additional 10% overstaff contingency which contributed to the increase in the Suitability of Staffing domain to 'Excellent'.

A range of audits and checks are completed by maintenance, kitchen, and domestic staff, with appropriate scheduling. Books and files did not contain any gaps. The home manager conducts and has oversight of regular audits. There was evidence of staff going back to audits to note when identified areas had been actioned.

Plans and Actions to Address Concerns and Improve Quality and Compliance

An action plan is in progress to address the one area of improvement found. This will be monitored by the Quality Assurance and Compliance (QuAC) Officer for compliance.

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 level of engagement with the Local Authority, responsive to both QuAC and Transformation teams and engages well with forums, initiatives, and training that is offered. Monthly reporting is submitted timely.

Engagement and Support from Transformation Managers

Ayresome Court engage fully with the Transformation Team, including the Well Led Programme, Provider Forums, training, networking and workshops, and the Activity Coordinator Network. The Transformation Team will continue to work with the home to identify new opportunities, including research projects and other initiatives.

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

Date of inspection

26 February 2020

Overall rating

Good