24 January 2023
During a routine inspection
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.