Pavilion Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection the service was not meeting all the legal requirements of regulation 12 (Safe care and treatment) due to issues with medicines management. At this inspection the service was no longer in breach of this regulation as improvements had been made. The service had made significant improvements in regard to medicines management. Some improvements were required in relation to records to support safe administration of medicines, however, all issues identified were rectified before conclusion of the assessment. The premises were not always safe. A number of issues around infection prevention and control, as well as the safety and presentation of the premises were identified during the assessment. The provider took immediate action to address the concerns. However, quality monitoring systems hadn’t identified most of those concerns observed during the first site visit. This was a breach of regulation 17 (Good governance). People were safeguarded from abuse. Risks to people’s health, safety and wellbeing were assessed and managed. There were enough trained and competent staff to meet people’s needs and safe recruitment practices were followed. The provider learned from accidents and incidents to mitigate future risks.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt safe to raise issues and would speak to the manager or deputy if something was wrong. People told us management were approachable and available. One person gave an example of how an issue they had raised about a staff member was actioned and the outcome fed back to them.

The registered manager explained the process for recording, monitoring and analysing incidents, accidents or errors. These included lessons learned and how these were communicated with staff members. For example, staff meetings and via the provider’s electronic system.

Accidents and incidents were recorded, monitored and analysed to reduce the risk of reoccurrence. Lessons learned from incidents were shared with staff both verbally, during handovers and in writing for all staff to read and sign, to confirm they understood.

People found the care and support provided met their needs. They felt involved in the design and delivery of their care. People and relatives were regularly consulted about the care they received. They found staff were competent, caring and treated people in a dignified manner. Relatives told us they could be involved in care planning for their family members and felt there was good communication from the home if there was any concerns or health changes.

The registered manager explained the admission process including liaising with external professionals for example hospital discharge teams and social workers. The registered manager provided two examples where people were identified to have needs that exceeded the care they could receive at Pavilion Court. The registered manager explained how the service worked with a multidisciplinary team to ensure smooth and safe transitions for both people to more suitable services and explained how their outcomes were both positive.

Professionals had no concerns about the service and felt the correct processes were in place to support a smooth admission process. A professional told us, “Very good processes in place offering good care - no issues with equity. There is clear promotion of self-care, where relevant and support for activities of daily living, as needed. Excellent communication and practice.”

Systems were in place to support people to transition safely and smoothly into the home and there was continuity of care. The provider had a range of policies and procedures in place to manage risk and monitor the safety of both people and staff. Care plans contained up to date information about people’s needs and preferences to enable staff to provide appropriate care. Risk assessments were in place and supported staff to identify and manage risks.

Staff supported people to keep them safe from harm. People told us that staff know them well. One person said, “I feel safe. I can raise any issues, but I haven’t had any specific incidents.”

Staff knew people well and were aware of how to report any safeguarding issues or concerns. Staff had completed safeguarding training to support their knowledge.

Staff were observed to have positive relationships with people who they clearly knew well. Care and support was provided in a respectful way which reassured people and supported them to feel safe.

Systems and processes were in place to safeguard people from the risk of harm. Where safeguarding concerns had been raised, they were appropriately investigated, lessons were learnt, and action taken to minimise the risk of reoccurrence. Relevant policies and procedures were in place.

People and their relatives told us they were involved in discussions around care plans and risk assessments. One relative said, “We did the care plan with the Community Psychiatric Nurse (CPN) and care home staff and we have reviews. They are looking after [person].”

Staff had a good understanding of people’s needs and risk management strategies supported them to provide care and support for people in a safe and supportive way. This approach enabled people to maintain their independence as far as possible.

We observed staff providing safe care and support. Staff supported people safely with their moving and handling needs, following care plans and using equipment appropriately.

Processes were in place to assess and manage risks, with the involvement of the person and their representative if relevant and appropriate. Risks were assessed and management plans developed which were regularly reviewed.

People told us that they felt comfortable in the environment and that temperatures were suitable. Some people raised concerns regarding the noise levels in the home, particularly for rooms next door to the lounge where the TV and/or music was often being played loudly. We fed this back to the registered manager.

The registered manager told us that the estates team ensured premises and equipment were safe, following any escalation from staff. The registered manager checked the safety of the premises during daily walkarounds. However, most of the issues and concerns identified during day 1 of the site visits were not detected through these processes.

We observed some areas of disrepair in the home, such as bare wood exposed in a bathroom, plaster coming away from the walls, and a broken toilet. Two fire doors labelled ‘keep locked' were open. General and clinical waste bins were found unlocked in an unsecured area. Oxygen tanks were not secure or stored appropriately. We observed one pull cord that was too short, others that were tucked away out of reach and one that was too long and trailing on the floor, creating a tripping hazard. The provider took action to rectify these issues. Fire escape routes were free from obstruction. We observed a bike and cardboard box in one area; however, the registered manager took immediate action to remove those items. People had personal emergency evacuation plans in place that reflected their needs and a grab bag was up to date and accessible to staff in the event of a fire.

Processes were in place to monitor and assess the environment and equipment to identify and control any potential risks. Appropriate safety checks were completed and an environment and refurbishment plan was in place and being followed. However, this did not include most areas of risk and disrepair observed during the first day of site visits.

There were enough staff with the correct skills, knowledge and experience to safely meet people’s needs. A relative said, “I think [person] is safe and have nothing to complain about. The assistant practitioner on his floor is very good and answers your questions, she is very knowledgeable.”

The registered manager determined staffing levels in line with people’s individual support needs. A consistent team of agency staff were used to support staffing levels.

We observed staff present around the home, supporting people throughout the site visits. Call bells were answered quickly, when sounded.

Staff were recruited in a safe way. The provider had an effective recruitment and selection policy and procedure in place which included all appropriate checks. Agency staff were also subject to appropriate checks prior to working in the home. Staff completed a comprehensive induction prior to working in the home. They received regular training and had their competence checked. Staff received regular supervisions and annual appraisals to ensure had the correct skills and knowledge to provide support people effectively.

People’s environment wasn’t always clean and hygienic. People had no concerns around the environment. Relatives felt the home was clean and well maintained, and that staff wore PPE. However, during day 1 of the site visits, we observed concerns with infection prevention and control.

Staff had no concerns about the environment. The registered manager informed us they completed a daily walk around the home to identify any issues or concerns. However, they hadn’t identified most of the issues we observed during the first day of site visits.

The décor of the home did always not promote effective infection control. Some areas of paintwork were damaged/chipped and therefore difficult to keep clean. On the first day of the site visits we observed personal care items left in multiple communal bathrooms and some areas of the home to be unclean, such as sinks, baths and flooring. We also observed a waterproof leg covering left in a bathroom and a discoloured plastic bags used in place of plugs in baths and sinks. Some pull chords didn’t have a protected sheath to promote effective cleaning. On the second day of site visits, we found all areas of the home to be clean and tidy and a decorator was scheduled to repaint the chipped woodwork.

There were cleaning schedules and quality monitoring systems in place, including daily audits and management daily walkarounds. However, they were ineffective in identifying concerns we observed on the first site visit.

Records demonstrated that people were receiving their oral medicines as prescribed. However, guidance to support staff in the administration of when required medicines required further improvement, for example we found one guidance document for an epilepsy medication which contained incorrect instructions. Documents to record application of topical medicines were in place for most people and records assured us people were receiving their topical medicines as prescribed. Some care plans required updating and lacked key information to aid staff in the safe delivery of care for complex conditions. This was escalated to management and care plans were in place for conclusion of the assessment.

Staff had competency assessments in place for medicines management. However, further work was required to ensure staff were appropriately trained in topical medicine application. Audits were taking place in the service, however, they were not identifying all the issues we found whilst on inspection. Senior management took immediate action in relation to inspection findings and all issues which were identified were rectified before conclusion of this assessment.

Medicines were stored securely and safely including controlled drugs. Temperature monitoring was taking place and medicines were stored within the appropriate limits. Processes to manage recording of thickening agents (medicines used to thicken food and fluid due to swallowing difficulties) were in place. On one floor we did find some discrepancies with the recording of the amount of thickener however this was not replicated on other floors throughout the service and immediate action taken when this was identified. For one person receiving medicines via a percutaneous endoscopic tube (PEG) no records could be provided to demonstrate cleaning and rotation of the PEG in line with their care plan. We were shown on day 2 of the inspection a regime to care for the PEG had been implemented.