CQC report explained · a nursing home
What the CQC found at Pavilion Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Requires Improvement; inspectors found risks involving medicines, choking and unsafe items, although care was effective and people were treated kindly.
This was an unannounced focused inspection. Inspectors visited on 6 April 2022 and reviewed information, the premises, care records for five people, medicine records for seven people and recruitment records for three staff. They also spoke with two people and five staff.
The main concerns were about safety. Staff did not always follow risk assessments. People at risk of choking or on special diets could access unsuitable food and drinks. Inspectors also found a hot kettle, knives and trip hazards. Medicines were not always recorded or given as prescribed.
The home was rated Good for Effective. Inspectors found personalised care plans, enough qualified staff, good support from other health professionals and appropriate consent processes. People appeared happy and staff were respectful and caring.
The overall rating was Requires Improvement. Safe remained Requires Improvement and Well-led fell from Good to Requires Improvement. The provider was asked for an action plan, and CQC said it would monitor progress.
Enough staff
Inspectors found there were enough staff to support people safely. Recruitment records included the required checks.
“Staff were safely recruited and there were enough staff to safely support people.” from the report
Personalised care
Care plans recorded people's choices, preferences and needs. People were involved in planning and reviewing their care.
“People's choices were clearly documented in the care plans and included their individual preferences.” from the report
Healthcare support
Staff worked with GPs, speech and language professionals and other healthcare services. People were supported to attend medical and dental appointments.
“Staff worked effectively with other healthcare professionals to make sure people's needs were fully met.” from the report
Respectful culture
People appeared happy and inspectors saw respectful, caring interactions. People and staff were positive about the new manager.
“During the inspection we observed staff interacting with people, relatives and each other in a respectful and caring way.” from the report
Medicines not always safe
seriousMedicine records did not always explain missed doses or the use of as-required medicines. Some patches were not used according to prescribing instructions.
“Medicines were not managed safely and we could not be assured people had received their medicines as prescribed.” from the report
Risks not controlled
seriousStaff did not always follow risk assessments. People who might not have understood the danger could reach unsuitable food and drinks, knives, a hot kettle and trip hazards.
“People were at risk of harm as staff were not following the provider's risk assessments or procedures.” from the report
Checks missed problems
needs fixingThe home's audits and daily checks did not identify all the medicines and environmental safety problems found by inspectors.
“The management team completed daily checks of the safety of the environment, but these did not reflect that staff were not following the provider's processes in place to keep people safe during the day.” from the report
- 01How have you corrected the problems with missed medicines, as-required medicine records and medicine patches?
- 02How do you now make sure staff follow each person's risk assessment?
- 03What has been done to prevent people at risk of choking from accessing unsuitable food, drinks or supplements?
- 04How are hot kettles, knives and trip hazards checked and removed during the day?
- 05What actions from the CQC action plan have been completed, and how do you check that the changes are working?
This was a focused inspection of Safe, Effective and Well-led; the report says ratings for questions not inspected were carried over from the last inspection. This explanation was written from the published report of 8 July 2022 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, February 2021
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was an announced, targeted inspection on 3 February 2021. It focused on how the home prevented and controlled infections during the coronavirus pandemic.
Inspectors found the home was clean, with regular cleaning of surfaces. Staff had suitable personal protective equipment and extra training. Visitors completed health declarations, were tested and had risk assessments before visits.
Inspectors were assured about testing, safe admissions, social distancing, shielding, hygiene, outbreak management and the home's infection prevention and control policy. The home was inspected but not rated, so this report does not give an overall quality rating.
Clean environment
The home was clean and surfaces were cleaned regularly. Furniture and the refurbished environment supported social distancing.
“The home was clean and there was regular cleaning of all surfaces.” from the report
PPE and staff training
Staff had access to suitable PPE throughout the home and had received extra training on using it and preventing infections.
“Staff had received additional training during the pandemic about correct PPE usage and infection prevention and control.” from the report
Safer visiting
The home used health declarations, testing and risk assessments for professional visitors. It also had a visiting room for risk-assessed visits with relatives when restrictions allowed.
“There was a designated visiting room at the home which allowed for risk assessed visiting between people and their relatives when restrictions allowed.” from the report
Keeping people connected
Fundraising paid for a large tablet to help people stay active, socialise and keep in touch with relatives during the pandemic.
“The registered manager and staff had carried out fund raising activities during the pandemic to purchase a large table e-tablet” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently testing people who use the service and staff?
- 02How do you now manage visits, including risk assessments and use of the designated visiting room?
- 03How do you make sure staff continue to use PPE correctly?
- 04What is your current plan for preventing and managing an infection outbreak?
- 05How do you make sure new people are admitted safely?
This was a targeted inspection of infection prevention and control arrangements during the coronavirus pandemic; the service was inspected but not rated. This explanation was written from the published report of 24 February 2021 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 Court
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- December 2018Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 2011.
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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36 live-in carers within about an hour of Newcastle upon Tyne
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,160 a week. 30 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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