Previously, we carried out a comprehensive inspection of this service on 13, 16 and 17 October 2017. At that inspection the service was rated 'Good' overall and there were no breaches of the regulations. After that inspection we received concerns in relation to staffing levels, the safety of people and the treatment received by people living at the home. As a result, we undertook another fully comprehensive inspection of Pavilion Court on 15 and 16 October 2018 to look into those concerns. At this inspection we identified a number of concerns and shortfalls which resulting in a breaches of regulations 9 (person centred care), 10 (dignity and respect), 12 (safe care and treatment), 17 (good governance) and 18 (staffing).
The provider had not adequately assessed the risks to the health and safety of people using the service, staff did not provide person centred care, staff demonstrated unsafe practice, people were not always treated with dignity and respect, people’s support needs were not met, staffing levels were not adequate to meet people’s needs and the governance of the service did not fully assess the quality of the care provided. During the inspection we raised four safeguarding alerts to the local authority due to concerns about the standard of care people were receiving. Following our site visit we also received additional whistleblowing concerns which we also shared with the Local Authority Safeguarding team.
You can see the action that we have asked the provider to take at the back of the full version of this report.
Pavilion Court is 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Pavilion Court can accommodate 75 people in one adapted building and on the date of this inspection there were 56 people living at the service. People received a mixture of residential and nursing care. Some people living at the home had a diagnosis of dementia or had fluctuating capacity.
Staff had received initial training around safeguarding vulnerable adults’ but we noted that this training had not been refreshed or completed by the majority of staff. Staff had received supervision sessions around safeguarding and could tell us what action they would take if they were concerned or witnessed any form of abuse. People told us they felt safe living at Pavilion Court Care Home and relatives agreed with these comments. There were policies and procedures in place to help keep people safe from abuse, these included the provider’s safeguarding vulnerable adults’ policy and information for people and relatives about reporting abuse.
We observed and were told by people that there were not always enough staff to support people when needed. The service assessed dependency needs for people which we reviewed as well as the staffing rotas for four weeks. The service frequently used agency staff but this had begun to reduce as new staff had been employed by the service. We observed that staffing levels on the second day of inspection were appropriate to support people. Staff, people and residents told us that at times there were not enough staff to support them, especially at night.
Staff did not always treat people with dignity and respect. We found records of people’s daily care in communal areas. Some people told us that they did not always know who was supporting them and that they did not receive the support they needed, when they needed it. Some people told us the staff spoke nicely to them and were caring. We observed people enjoyed positive relationships with some staff. We saw staff asking people for consent when supporting and asking for people's choices for meals and drinks.
There was an infection control policy in place at the home but this was not always followed by staff. Communal lounges and dining rooms were not clean. We saw housekeeping staff cleaning people’s bedrooms and communal bathrooms.
The home did not provide safe medicine management. Care plans for ‘as required’ medicines were not completed or absent from people’s care records. Procedures were in place to provide guidance on the receipt, storage, administration and disposal of medicines. There were records regarding other professionals involved in people's care. People's medicine care plans completely documented all the information needed to fully support people.
During the inspection we found that the premises were not always safe for people living at the home. The sluice room on the ground floor was open because the key pad lock was not working, the clinical waste bins were open and unlocked, and kettles containing boiling water were left on benches in areas where people could not fully assess the risk to themselves.
People were supported to maintain a balanced diet. However, people did not have access to a range of foods and fluids throughout the first day of our inspection, but we noted that there were different fluids and foods available on the second day of inspection. Food and fluids were easily accessible to people who could not make safe choices or who were at risk of aspiration and choking or who had special dietary requirements. These risks had not been identified or mitigated at the time of our inspection. People and relatives had mixed comments about the meals provided. Some people told us they liked the food and others told us that there was not much choice.
Staff received regular supervisions from the new registered manager and these included lessons learned from safeguarding incidents, complaints, best practice and accidents/incidents. Staff received a thorough induction from the provider before working within the home. Most staff training was out of date and the registered manager had arrangements in place to ensure that all staff received the mandatory and additional training sessions applicable to their role for the week after our inspection. Agency staff also received an induction from the provider before working at the service.
Most people had personalised risk assessments in place to keep them safe. People had care plans in place for general things, for example personal hygiene, mobility and sleeping and individual plans for specific things, such as, being unable to use the call bell. We noted that some care plans were illegible and the general care plans were very standardised. People, relatives and external health professionals were all involved in best interest decisions and mental capacity assessments. However, people's care records were not always accurate and up-to-date.
There was a new registered manager in post who had been registered with the Commission to provide the regulated activity since October 2018 and had worked at the service for approximately two months, this was one of the requirements of the home's registration with CQC. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Accidents and incidents were recorded correctly and if any actions were required, they were clearly documented and addressed. Lessons learned were shared with people, relatives and staff. Where appropriate, the registered manager had escalated these to the local authority as a safeguarding concern and notified CQC.
CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Most staff demonstrated their understanding of the MCA.
People and relatives knew how to raise a complaint or concern. There was information on how to make a complaint displayed within the service and this was accessible to everyone. Feedback was sought from people, relatives, staff and visitors to help continuously improve the service.
The management team had a clear vision to care for people living at the home and had plans in place to improve the quality of care provided to people. Staff told us that they were fully supported by the registered manager and were positive about the changes that they had introduced. Relatives said that they were always welcomed at the service and commented that the new manager took time to speak to them.
The registered manager and deputy manager carried out checks and audits of the service but these were not always documented or identified the issues we had identified. The provider did have a governance framework in place to monitor the quality and assurance of the service but this did not highlight all the issues we identified.
There was a new activities coordinator in post who was introducing a range of meaningful activities for people. We observed activities being carried out with large groups and in a one to one setting during the inspection. The service promoted advocacy and there was accessible information available detailing what support people could access to help make choices about their individual lives.
The service provided end of life care to people and the service was working with a partnership agency to provide palliative care in a designated unit at the home.
The premises were ‘dementia friendly’ and there was pictorial signage to help people orientate themselves. The communal areas of the home needed some refurbishment and the registered manager told us about plans already in place for this. People had personalised bedrooms.