CQC report explained · a nursing home
What the CQC found at Pavillion Residential and Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable staffing, recruitment checks, risk assessments, medicines systems and infection control arrangements.
- Effective?
- Good
- People's needs were assessed and reviewed, and staff had training and supervision. The home supported nutrition, healthcare access and lawful consent arrangements.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were offered choices and supported to express their views and maintain independence.
- Responsive?
- Good
- Care was personalised and records included people's histories, preferences and needs. People had activities, support with relationships and person-centred end-of-life care.
- Well-led?
- Good
- Inspectors found approachable management, effective communication and quality checks. People, relatives and staff were invited to give feedback and take part in decisions.
What inspectors found, June 2022
Pavillion Residential and Nursing Home was rated Good; inspectors found kind, safe care, with some building refurbishment still needed.
Inspectors reviewed all five areas: Safe, Effective, Caring, Responsive and Well-led. The inspection began remotely on 27 April 2022 and included an unannounced site visit on 9 June 2022.
People and relatives described staff as kind, caring and supportive. Inspectors found enough staff, safe medicines systems, suitable care records, good links with health professionals and support for people's choices, privacy and relationships.
Some parts of the building showed wear and tear. One top-floor unit was not well designed for people's needs, including people living with dementia. The provider had an action plan and was carrying out refurbishment. CQC recommended that this work continue promptly and follow best practice.
Kind and respectful staff
People and relatives spoke very positively about staff. Inspectors observed many positive interactions and found that staff knew people well.
“During the inspection we observed many positive interactions between people and staff. Staff knew people very well.” from the report
Safe staffing and medicines
Staffing levels were monitored and people said there were enough staff. Medicines records and risk assessments supported safe administration.
“Staffing capacity was sufficient and staff deployment was effective to ensure people's needs were met in a safe, timely way.” from the report
Personalised support
Care records described people's history, preferences, health and mental health needs. Staff supported choice and control in daily life.
“Care and support was person-centred giving people choice and control in their lives.” from the report
Good partnership working
The home worked with GPs, nurses, therapists, social workers and mental health professionals to support people's needs.
“Staff worked with a range of other professionals, including GPs, district nurses, speech and language therapy, social workers and the mental health team.” from the report
Approachable management
Staff, people and relatives described the manager as approachable. Audits, meetings and feedback were used to monitor and improve the service.
“A quality assurance system was in place and regular audits were completed to monitor service provision and to ensure the safety of people who used the service.” from the report
Building condition and design
needs fixingSome areas showed wear and tear. One top-floor unit was not environmentally designed appropriately for people's needs, including people living with dementia. CQC recommended that refurbishment continue promptly and follow best practice.
“Some areas of the building were showing signs of wear and tear and one unit on the top floor was not appropriately environmentally designed to meet people's needs.” from the report
- 01What refurbishment has been completed since the inspection, particularly on the top floor?
- 02What changes have been made to the top-floor environment to meet the needs of people living with dementia?
- 03How are staffing levels monitored on each shift, and what happens if staffing is lower than planned?
- 04How are medicines checked to make sure they continue to be given as prescribed?
- 05How will my relative and our family be involved in care reviews, activities and decisions about their daily life?
This was a comprehensive inspection covering all five key questions, with activity starting remotely on 27 April 2022 and a site visit on 9 June 2022. This explanation was written from the published report of 29 June 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 2022
Inspected but not rated; inspectors found strong COVID-19 infection control and visiting arrangements.
This was an announced, targeted inspection on 31 January 2022. Inspectors checked infection prevention and control, visiting arrangements, and whether staffing pressures affected care.
The home had regularly updated COVID-19 procedures. Inspectors found suitable testing, screening, personal protective equipment, cleaning and hand hygiene arrangements. Staff were observed using protective equipment correctly.
The home supported visits through an outdoor visiting pod and indoor visiting. Inspectors were assured that infection risks were being managed, but the service was not given a rating.
Infection control planning
The home had detailed procedures for managing COVID-19 risks, and these were updated when national guidance changed.
“Comprehensive policies and procedures were in place to manage any risks associated with the COVID-19 pandemic.” from the report
Testing and protective equipment
People, staff, essential carers and visitors were included in regular testing. Inspectors saw staff using protective equipment correctly, and supplies were available.
“There was an ample supply of PPE for staff and visitors to use.” from the report
Contact with relatives
The home provided an outdoor visiting pod and also allowed indoor visits, helping people stay in contact with relatives.
“People living in the home and their relatives were supported to maintain contact.” from the report
Visiting and community access
Inspectors found that visiting guidance was followed and that people could leave the home to see relatives or use the local community.
“People were supported to leave the service to visit relatives or access the local community.” from the report
Inspectors raised no specific concerns in this report.
- 01What has changed in your infection control and visiting arrangements since the inspection on 31 January 2022?
- 02How do you now manage staffing pressures, and how do you check they are not affecting people's care?
- 03Is the unit that was closed for refurbishment now open, and how many people are currently living in the home?
- 04What checks are made before visitors and professionals enter the home?
- 05What arrangements are available now for relatives who want indoor or outdoor visits?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not provide a full rating of the service. This explanation was written from the published report of 5 February 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.
Every inspection of Pavillion Residential and Nursing Home
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- June 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pavillion Residential and Nursing Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Pavillion Residential and Nursing Home →
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2016Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not rated
- August 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2014Requires improvementSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2020
Registered with the Care Quality Commission on 15 September 2020.
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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