Archived: Pavillion Residential and Nursing Home

Updated 8 January 2020

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 Care Act 2014.

Inspection team

The inspection team was made up of one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pavillion Residential and Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We also contacted Healthwatch. 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.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection-

We spoke with ten people and five relatives about their experience of the care provided. We spoke with eight members of staff including the regional manager, registered manager, the kitchen manager, two nurses, two care workers and an activities staff member. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed documentation, inspected the safety of the premises and carried out observations in communal areas. We reviewed a range of records. This included three people’s care records and medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 8 January 2020

About the service

Pavillion Residential and Nursing Home provides care and accommodation for up to 68 people with nursing care needs and people who are living with dementia. At the time of the inspection the service supported 57 people.

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

People felt very safe and secure living in the home. They were happy with the service and spoke highly of staff members, describing them as “really nice”, “lovely” and “kind.”

Risks were well managed. Staff felt confident safeguarding people from abuse and the registered manager raised safeguarding alerts in a timely way. Arrangements were in place for the safe administration of medicines. Staff were recruited in a safe way and there were enough staff on duty to meet people’s needs. The provider learned from previous accidents and incidents to reduce future risks. The premises were clean and tidy.

People’s needs were assessed before they received support. Staff were suitably trained and received regular supervisions as well as annual appraisals. People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People were supported with their nutritional needs and to access a range of health care professionals.

People were well cared for and supported in a dignified manner. Staff treated people with respect and promoted their independence by encouraging them to care for themselves, where possible. People were supported to access advocacy services, when needed.

Care plans were person-centred and detailed. People’s communication needs were assessed, and staff knew how to communicate with them effectively. People and relatives had no complaints about the service but knew how to raise concerns. Any complaints received were fully investigated and subsequent action was taken. The service organised a wide range of activities for people to enjoy both inside the home and in the local community.

People and relatives were complimentary about the service. One person said, “It is well led. I would recommend it here.” An effective quality assurance process was in place. People and relatives were regularly consulted about the quality of the service through surveys and meetings. Staff were involved in the ongoing development and improvement of the service through regular meetings.

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 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.