Pavilion Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Governance systems were in place which were effective in driving improvements in some areas. However, the process for monitoring the quality of infection prevention and control and the safety and presentation of premises failed to identify the concerns we found during the assessment. This was a breach of regulation 17 (Good governance). The provider worked with the registered manager and staff to promote a shared vision, mission and values. The registered manager promoted a positive culture in the home and staff felt confident to raise any issues and concerns. There were systems in place to promote an inclusive culture in the home, which consistently looked at how to improve equality and diversity for the people they supported and their workforce. The registered manager understood the legal requirements of their role and responsibility. The registered manager and staff worked in partnership with other health professionals to achieve positive outcomes for people.

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.

The registered manager and staff promoted a positive culture in the home. A recent staff survey demonstrated that staff were generally happy in their roles and felt they were able to share their views about potential issues or improvements. People and relatives were positive about the atmosphere in the home. They said, “It’s a pleasant atmosphere. I am happy with the service” and, “It’ homely and they are open to suggestions.”

Processes were in place to help staff and leaders demonstrate a positive, compassionate, listening culture, focused on learning and improvement. The vision, values and quality of the service was discussed with staff regularly through supervisions and meetings. The provider’s policies and procedures promoted an open and honest culture throughout the service.

Management had the experience, capacity, capability to ensure the organisational vision was delivered. The registered manager and deputy manager understood their roles and responsibilities and acted on the duty of candour. They conducted themselves in an open and honest way and submitted statutory notifications for significant events that occurred in the home.

Processes were in place to recognise and reward positive staff practices, which evidenced leaders were compassionate and inclusive. A system was in place to involve people, relatives and staff in the running and development of the home. The registered manager consulted with key stakeholders through a variety of methods, to capture their views and make inclusive decisions about service improvement.

Staff felt management were approachable and they could raise any issues or concerns. The registered manager told us they hadn’t received any whistle-blowing concerns as yet, but that they would ensure they protected the identify of staff and anonymise statements where required, when conducting an investigation.

The provider had an up-to-date whistleblowing policy and this was on display in the home, to encourage staff to come forward and raise any issues or concerns and feel protected when doing so.

Staff felt valued and respected in their roles. They were well-supported by the registered manager and deputy manager both professionally and personally.

Processes were in place which helped to protect the rights of staff under the Equality Act. The provider had policies in place to support staff who may require additional risk assessments and reasonable adjustments to enable to them to carry out their roles effectively, promoting inclusivity. Equality and diversity was regularly discussed during staff meetings. Discussions around supporting staff and people and promoting equality, diversity and equal opportunities in the home.

Staff felt the service was well run and people were supported in a safe way. The registered manager explained the range of processes they use to monitor the quality and safety of the service including audits, observations and meetings. However, these did not identify most of the issues found during the assessment.

The systems in place for checking the quality and safety of the service were not always effective as they failed to identify the shortfalls in practices detailed in this report. Shortfalls were identified in relation to infection prevention and control and the safety and presentation of the premises.

People and relatives told us staff worked with a range of health professionals so they could access appropriate care and treatment, when required.

The registered manager and staff worked in partnership with other health professionals to achieve positive outcomes for people.

External professionals spoke positively about the service and staff. One professional told us, “Overall excellent working with myself and all care staff especially the lead nurse and manager.”

People's care records showed involvement and guidance from other agencies such as GP, dentist, physiotherapist, CPN (Community Psychiatric Nurse), social worker, pharmacist, behavioural support team, district nurse, paramedics and chiropodists.

The provider was focused on continuous learning and improvement and keeping up-to date with best practice to ensure people's needs could be met. The registered manager and deputy manager promoted continuous learning with staff. The registered manager told us they were really committed to training; mandatory training levels were above 95% at the time of the assessment, with further training scheduled to take place soon.

Systems for monitoring standards of care were in place to identify areas of improvement and lessons learnt. This included regular audits of falls, safeguarding concerns and complaints, to identify any themes, trends and lessons learned. Records showed staff were recruited, trained and supervised appropriately.