CQC report explained · a residential care home
What the CQC found at Pavilion Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely or given at the correct time. Staffing levels, emergency evacuation plans and access to hazardous areas also created safety concerns.
- Effective?
- Requires improvement
- Menus were not always varied and people were not always offered balanced choices. Staff training, care assessments, health referrals and support under the Mental Capacity Act were positive.
- Caring?
- Requires improvement
- Staff could not always spend enough time with people, and personal care was sometimes delayed. Inspectors saw examples where privacy, dignity and respectful communication were not maintained.
- Responsive?
- Requires improvement
- Care plans were not always followed and one end of life care plan contained conflicting information. Complaints were not recorded consistently, although activities and support to maintain relationships were provided.
- Well-led?
- Requires improvement
- Management checks did not reliably identify risks or ensure that actions were completed. The new manager was engaging with people, staff and relatives and had identified areas for improvement.
What inspectors found, March 2023
Pavilion Care Centre was rated Requires Improvement; inspectors found unsafe medicines management, staffing gaps and failures to protect dignity.
Inspectors made an unannounced visit on 24 January 2023. They spoke with people, relatives and staff, and reviewed care plans, medicine records, staff files and management records.
They found problems across all five areas inspected. Medicines were not always given safely or on time. There were not always enough staff, emergency evacuation plans were incomplete, and people could enter some hazardous areas. Personal care was sometimes delayed and privacy and dignity were not always respected.
Care planning, complaints records and quality checks were not always reliable. The home did provide staff training, supported people to make choices, and helped people access health professionals and activities.
The overall rating and each of the five question ratings changed from Good at the previous inspection to Requires Improvement. The provider was asked to send an action plan and progress will be monitored.
Staff training
Staff received induction, refresher training, supervision and specialist dementia training. Inspectors found they had the skills and knowledge needed to support people.
“Staff were trained effectively to meet the needs of people in the home.” from the report
Choice and consent
People were supported to make their own decisions where possible. Best-interest decisions and relevant legal safeguards were documented.
“The provider worked in line with the MCA.” from the report
Health support
The home worked with health and social care professionals and made referrals in a timely way.
“The provider maintained close working relationships with other agencies.” from the report
Activities and relationships
People had access to individual and group activities, and care plans included support to maintain important relationships.
“Individual and group activities took place at the service based upon people's wishes and preferences.” from the report
Medicines
seriousMedicine records were sometimes unclear, guidance for medicines given when needed was incomplete, and medicines were not always given at the prescribed time. This created a risk of medicine errors and harm.
“Medicines were not always managed safely.” from the report
Staffing and supervision
seriousThere were times when staff could not respond promptly to call bells or meet people's needs. One person who required observation was left alone in a communal area.
“There were not always enough staff to meet people's needs.” from the report
Privacy and dignity
seriousInspectors saw personal care discussed loudly in a communal area and an undignified moving and handling technique. Personal care was also sometimes delayed.
“People were not consistently treated with respect and their dignity was not always maintained.” from the report
Emergency safety
needs fixingPersonal emergency evacuation plans were not in place for everyone and emergency information was out of date. People could also enter unlocked areas where knives were stored.
“People were not always kept safe from hazardous areas.” from the report
Management checks
seriousAudits and checks did not consistently identify problems, record complaints, learn from incidents or make sure actions were completed.
“Governance processes were not always operated effectively to identify where improvements were required.” from the report
Care planning and meals
needs fixingSome care plans were not followed, including a person's preferred place to eat and required observation. Menus were not always varied and alternatives were not always offered.
“Care plans were not always followed by staff.” from the report
- 01What has changed to ensure there are enough staff on every shift, and how are call bell response times now monitored?
- 02How are medicine records checked, especially for medicines given as needed, topical creams and medicines due at particular times?
- 03Are personal emergency evacuation plans now complete and up to date for every resident?
- 04How do staff protect privacy and dignity during personal care, moving and handling, mealtimes and conversations?
- 05How are complaints, accidents and audits now recorded, reviewed and followed through to completion?
This was an unannounced scheduled inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 18 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2019
Rated Good in all five areas; inspectors found safe, kind and personalised care, with improvements in activities since the last inspection.
This was an unannounced scheduled inspection by one inspector on 4 December 2018. The inspector spoke with people living at the home, a relative and staff. They also observed care, reviewed five care plans, medicines records and the home's quality checks.
The home was rated Good overall and Good for Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training and good links with health professionals. People were treated with kindness and respect, and their care was personalised.
The report says the range of activities had improved since the previous inspection. The home had also introduced an electronic care system, which was still being brought into use. Inspectors found that the home met legal requirements and that its systems were being used to monitor and improve care.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs safely. Medicines systems covered receipt, storage, administration and disposal.
“There were enough staff to ensure that people's needs were met safely.” from the report
Kind, respectful care
People had positive relationships with staff, who supported their dignity, privacy, choices and personal beliefs.
“People had caring, kind supportive relationships with the staff who supported them.” from the report
Improved activities
The home had improved its activities programme since the previous inspection. Activities were linked to people's interests and included individual as well as group support.
“At our last inspection we found that people were not always provided with a good range of activities. At this inspection this had improved.” from the report
Quality monitoring
The home used regular audits and reports to monitor areas such as medicines, infection control, falls, weights and skin damage risks.
“There were quality audits in place to measure the success of the service and to continue to develop it.” from the report
Personalised records
Care plans included people's preferences and were regularly reviewed. The new electronic system gave staff current information during the day, although it was still being introduced.
“There were care plans in place which were detailed and regularly reviewed.” from the report
Inspectors raised no specific concerns in this report.
- 01How is the electronic care system working now that it has been introduced, and how do you check that staff record information accurately?
- 02What extra checks are currently used after the medicines management errors mentioned in the report?
- 03How are activities planned around my relative's interests, and how do you provide individual attention as well as group activities?
- 04Are all current Deprivation of Liberty Safeguards applications and authorisations up to date?
- 05How often are my relative's care plans reviewed, and how are they updated when their needs or choices change?
This was an unannounced scheduled inspection that looked at the home, the care provided and all five CQC questions. This explanation was written from the published report of 3 January 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pavilion Care Centre
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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