Pavilion Care Centre

Updated 18 March 2023

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 3 Inspectors 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

Pavilion Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Pavilion Care Centre is a care home without nursing care. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both 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 who intends to deregister. A new manager had recently started and intends to register, they will replace the current manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

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 annually with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with 4 people that used the service and 10 relatives about their experience of the care provided. We spoke with 7 members of staff including a manager, senior care worker, care workers and a maintenance engineer.

We reviewed a range of records. This included care records for 5 people and multiple medication records. We looked at 2 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 also reviewed.

Updated 18 March 2023

About the service

Pavilion Care Centre is a residential care home providing personal care to up to 30 people. The service provides support to people aged 65 and over, some of whom were living with dementia. At the time of our inspection there were 24 people using the service. The accommodation is across three floors, with communal areas on the ground and first floors and more independent living in flats on the third floor.

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

Medicines were not always safely managed. Medicine administration records were not always legible. Medicines were not given in a timely manner. Records relating to medicines which were required 'as needed' did not provide staff with instructions how to safely give these types of medicines and reasons for their administration were not always recorded. There were not always enough staff on duty to safely meet people’s needs. Emergency evacuation plans were not always in place or updated. People were able to access high risk areas of the home such as the kitchen and laundry as they were unlocked.

Staff were not able to spend quality time with people and did not always respect people’s privacy and dignity. Personal care was not always given in a timely manner and had impacted on people’s dignity. Communication between staff was not always respectful as care needs were discussed loudly in a communal area and people were referred to as room numbers.

We have made a recommendation about complaints as records for received complaints were not maintained and there were no lessons learned. Accidents and incidents were not monitored for trends, quality assurance checks were completed remotely on care records held electronically. Management audits and checks were not regularly completed, and actions were not always identified or followed up.

People were not always offered a balanced diet and alternative choices were not always offered. Signage to support people to orientate was limited. Staff received regular training and specialised training such as dementia. 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.

Relatives were not always sure of the outcomes of complaints. Care planning information was not always reflective of care given and end of life wishes in one person’s care plan contained conflicting information.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (published 04 January 2019).

Why we inspected

This was a scheduled inspection based on previous rating.

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.

Enforcement

We have identified breaches in relation to medicines management, quality assurance systems, staffing and maintaining people's privacy and dignity. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.