Elton Hall - 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

8 December 2025

Date assessment was published

17 December 2025

Date previous assessment was published

21 March 2025

PAMMS Assessment Summary (Positive Outcomes, Observations and Concerns)

The home uses an electronic care planning system (PCS) that enables highly personalised care plans. Each resident's profile includes a photograph, room number, and a clear summary of their risks, care needs, medical history, preferences, required equipment, and key contacts.

An 'About Me' section is included for every resident, capturing personal preferences, significant relationships, communication needs, and individual do's and don'ts. Care updates are logged in real time throughout the day, with visual indicators amber for overdue tasks and green for completed ones.

Care plans incorporate Deprivation of Liberty Safeguards (DoLS) and capacity assessments. Each DoLS plan records application and expiry dates, with status displayed prominently on the homepage. While initial gaps in identifying residents subject to DoLS were noted, these were promptly corrected during the assessment.

Staff interactions consistently demonstrated dignity and respect. Observations confirmed that team members encouraged independence, knocked before entering rooms, introduced themselves, and prioritised residents' well-being.

A varied activity programme, led by three Activity Coordinators, ensures daily engagement. Recent activities included a church service, Christmas show, arts and crafts, movie afternoons, bingo, shopping trips, and one-to-one sessions. Residents were actively involved, and photographs of these events are displayed throughout the home.

Risk assessments are embedded within care plans, and Personal Emergency Evacuation Plans (PEEPs) are maintained in both electronic and printed formats, reviewed monthly. Malnutrition Universal Screening Tool (MUST) assessments are monitored consistently. Daily charts track mobility, toileting, meals, mattress checks, and hygiene, with accurate, live updates recorded via PCS. Food and fluid intake is logged daily, and a health passport can be generated from the system.

The manager conducts regular audits, recording actions in a Service Improvement Plan monitored by the regional manager. Key Performance Indicator (KPI) data is reviewed to identify trends and address issues. Fire safety compliance is strong, with checks on alarms, detectors, emergency lighting, and equipment. A full fire risk assessment was completed in October 2025, and drill records are maintained. A compliance matrix ensures all safety documentation Fire Risk Assessments, Portable Appliance Testing (PAT) testing, gas and electrical certificates, Legionella monitoring, and water temperature checks is up to date. Additional audits cover bed rails, mattresses, and window restrictors.

The home maintains a calm, secure environment with positive staff-resident relationships. Staff demonstrated clear knowledge of safeguarding, whistleblowing, and escalation procedures. The building blends historical character with modernisation, supported by a phased refurbishment plan. Bathrooms have been upgraded, and while some areas show age, all spaces remain clean, organised, and clutter-free. The home achieved a 5-star food hygiene rating in March 2025.

Infection control is overseen by a dedicated champion who monitors hand hygiene, conducts observations, and attends network meetings and training. The medication room is clean, organised, and secure, with Controlled Drugs stored in locked cupboards and medication trolleys secured when not in use.

Dementia-friendly design features such as colour-coded handrails, distinctive bedroom doors, and clear bathroom signage are evident. The manager adheres to the Stockton Dementia Friendly Care Home Guide and meets local authority standards.

Medication policies are current and include guidance on home remedies and covert administration, last reviewed in August 2025. Staff competencies align with the council's contract requirements, with six-monthly assessments. Care plans show evidence of supporting residents with annual health checks and medication reviews. Medication labelling is generally clear, with only minor exceptions noted.

Medication administration is recorded on paper Medication Admin Record (MAR) charts. Staff verify charts against medication labels upon receipt, with a second team member confirming accuracy. Observations confirmed records were complete and free from gaps. Discrepancies are addressed promptly through audit processes. Regular audits cover MAR chart reviews and controlled drug counts, with findings and corrective actions documented.

Staffing levels were appropriate, with team members visible and responsive and call bells were answered promptly. Interactions reflected a calm atmosphere and positive relationships.

A review of staff files confirmed all mandatory checks, including DBS certification, employment history, references, contracts, health checks, and right-to-work documentation. New staff complete shadow shifts and a structured induction within 12 weeks, following Skills for Care standards. Induction booklets are signed by mentors and managers. NVQ Level 3 staff follow the same process. Medication competencies are reviewed every six months. All staff have received supervision and appraisal within the past year, with bi-monthly supervision sessions in line with local authority requirements.

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 - standard monitoring

Level of Engagement with the Authority

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

Engagement and Support from Transformation Managers

Elton Hall engages well with the Transformation Team, and have participated in Provider Forums, Activity Coordinator Network and other opportunities offered, as well as communicating with the Transformation Managers around training and requests for information. We will continue to promote further innovative opportunities such as research and more collaborative working.

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

Date of inspection

5 February 2022

Overall rating

Good