Pavilion Court

Updated 8 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by two inspectors.

Service and service type

Pavilion Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pavilion Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. There was a newly appointed manager who was in the process of completing their registration with the CQC to become the registered manager.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 6 April 2022 and ended on 19 May 2022. We visited the location on 6 April 2022.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We reviewed the information we held about the service. This included any statutory notifications received. Statutory notifications are specific pieces of information about events, which the provider is required to send to us by law.

We sought feedback from the local authority contracts monitoring, safeguarding adults' teams and NHS Clinical Commissioning Group (CCG), who commission services from the provider, and asked the local Healthwatch for their feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our inspection.

During the inspection

We reviewed documentation, inspected the safety of the premises, reviewed documentation and carried out observations in communal areas.

We spoke with two people who used the service and five members of staff including the manager, regional manager and three care assistants. We reviewed the care records for five people, medicine records for seven people and the recruitment records for three members of staff.

Updated 8 July 2022

About the service

Pavilion Court is a residential care home providing personal and nursing care to up to 75 people. The service provides support to people aged 18 and over, some of whom were living with a dementia. At the time of our inspection there were 48 people using the service.

People’s experience of using this service and what we found

People were at risk of harm as staff were not following the provider’s risk assessments or procedures. We found where people were identified at a risk of choking or were required to follow a special diet, food and drinks were easily accessible. Staff had not removed all health and safety risks which placed people, who may not have had the capacity to make safe choices, at risk of potential harm.

Risk assessments were in place and these were reviewed by the manager and regional manager. The quality and assurance systems in place were generally effective to monitor the safety and quality of the care provided but were not fully effective for medicines management.

Medicines were not always managed safely. People’s records did not include all of the details of medicines administered. Topical medicine records showed patches were not always administered as prescribed. Management audits had highlighted the issues with medicine administration but did not highlight all areas of concern.

People had personalised care plans in place which detailed their own choices and preferences. Staff worked in partnership with other healthcare professionals to make sure people had all of their needs met. There was enough qualified staff to safely support people.

People were observed to be happy living at the home and interacting positively with each other and staff. People were supported to be as independent as possible.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 July 2019).

Why we inspected

We received concerns in relation to the safety of care provided to people. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pavilion Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management and medicines management at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.