Pavillion Residential and Nursing Home

Updated 29 June 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 carried out by 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 and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pavillion Residential and Nursing Home 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 a registered manager in post.

Notice of inspection

The start of the inspection was announced and the site visit was unannounced.

We gave a short period of notice at the start of the inspection, which was carried out remotely, so the registered manager could send the required records.

Inspection activity started remotely off site on 27 April 2022 and a site visit took place on 9 June 2022. The inspection ended on 9 June 2022.

What we did before the inspection

We reviewed information we had received about the service since it was registered, including the notifications of accidents and incidents we had received from the provider. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

During the inspection we communicated with seven people who used the service and 19 relatives about their experience of the care provided. Not everyone who used the service communicated verbally or wished to speak on the telephone, therefore they gave us permission to speak with their relative. We spoke with 12 members of staff including the registered manager, a visiting peripatetic manager, registered nurse, two senior support workers, six support workers and one domestic staff. We received feedback from two health and social care professionals.

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 a range of records. This included six people’s care records and multiple medicines records. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including training information and policies and procedures, were reviewed.

Updated 29 June 2022

Pavillion Residential and Nursing Home is a care home that provides accommodation and personal and nursing care to up to 68 older people, including people who may live with a dementia. At the time of our inspection there were 50 people using the service.

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

People and relatives were complimentary about the care provided by staff. They trusted the staff who supported them. They said staff were kind, caring and supportive of people and their families. One relative said, “Staff are nothing but caring” and “It’s not a job for them it’s a vocation. As [Name] doesn’t know me now, they are [Name]’s new family. I get comfort knowing that they are happy there.”

Staff received safeguarding training and were clear on how and when to raise their concerns. Where appropriate, actions were taken to keep people safe.

Staffing capacity was sufficient and staff deployment was effective to ensure people's needs were met in a safe, timely way. Systems were in place for people to receive their medicines in a safe way.

There were opportunities for staff to receive training, to give them insight into people’s support needs.

Records provided guidance to ensure people received safe, person-centred care and support from all staff members.

There was evidence of collaborative working and communication with other professionals to help meet people's needs.

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.

People's diversity as unique individuals with their own needs was respected by staff. The staff team knew people well and provided support discreetly and with compassion. People’s privacy was respected, and people were supported to maintain contact with relatives.

There was a cheerful atmosphere at the service. Staff spoke positively about working at the home and the people they cared for. Staff said the manager was very approachable and they were supported in their role.

People received a variety of food and drink to meet their needs and any specialist diets were catered for.

Some areas of the home were showing signs of wear and tear and a programme of refurbishment was taking place. We received an action plan to show timescales for completion and how the home would be designed environmentally to meet the needs of all people.

We have made a recommendation that the provider continues with the programme of refurbishment in a timely way, and follows best practice guidance with regard to environmental design.

The service was following safe infection prevention and control procedures to keep people safe.

A quality assurance system was in place to assess the standards of care in the service. A relative commented, “We visited a number of care homes and we considered this one to be the best.”

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

Rating at last inspection and update

This service was registered with us on 15 September 2020 and this is the first inspection.

The last rating for the service under the previous provider was good, published on 8 January 2020.

Why we inspected

The service was inspected and all domains were reviewed as it has not been previously rated under the new provider. The inspection was prompted in part due to concerns received about people’s care and staff attitude. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see all sections of this full report.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.