We carried out a review of the data available to us about Pavillion Residential and Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pavillion Residential and Nursing Home, you can give feedback on this service.
People’s experience of using this service and what we found
People and relatives were complimentary about the care provided by staff. They trusted the staff who supported them. They said staff were kind, caring and supportive of people and their families. One relative said, “Staff are nothing but caring” and “It’s not a job for them it’s a vocation. As [Name] doesn’t know me now, they are [Name]’s new family. I get comfort knowing that they are happy there.”
Staff received safeguarding training and were clear on how and when to raise their concerns. Where appropriate, actions were taken to keep people safe.
Staffing capacity was sufficient and staff deployment was effective to ensure people's needs were met in a safe, timely way. Systems were in place for people to receive their medicines in a safe way.
There were opportunities for staff to receive training, to give them insight into people’s support needs.
Records provided guidance to ensure people received safe, person-centred care and support from all staff members.
There was evidence of collaborative working and communication with other professionals to help meet people's needs.
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.
People's diversity as unique individuals with their own needs was respected by staff. The staff team knew people well and provided support discreetly and with compassion. People’s privacy was respected, and people were supported to maintain contact with relatives.
There was a cheerful atmosphere at the service. Staff spoke positively about working at the home and the people they cared for. Staff said the manager was very approachable and they were supported in their role.
People received a variety of food and drink to meet their needs and any specialist diets were catered for.
Some areas of the home were showing signs of wear and tear and a programme of refurbishment was taking place. We received an action plan to show timescales for completion and how the home would be designed environmentally to meet the needs of all people.
We have made a recommendation that the provider continues with the programme of refurbishment in a timely way, and follows best practice guidance with regard to environmental design.
The service was following safe infection prevention and control procedures to keep people safe.
A quality assurance system was in place to assess the standards of care in the service. A relative commented, “We visited a number of care homes and we considered this one to be the best.”
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
This service was registered with us on 15 September 2020 and this is the first inspection.
The last rating for the service under the previous provider was good, published on 8 January 2020.
Why we inspected
The service was inspected and all domains were reviewed as it has not been previously rated under the new provider. The inspection was prompted in part due to concerns received about people’s care and staff attitude. A decision was made for us to inspect and examine those risks.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see all sections of this full report.
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
We found the following examples of good practice.
Comprehensive policies and procedures were in place to manage any risks associated with the COVID-19 pandemic. This included the management of people with a COVID-19 positive diagnosis. The policies and procedures were updated regularly following any changes in national guidance.
The registered manager had identified, assessed and mitigated COVID-19 related risks to people, staff and visitors.
A programme of regular COVID-19 testing for both people in the home, staff, essential carers and visitors to the home was implemented. All visitors, including professionals were subject to a range of screening procedures, including showing evidence of vaccination and a negative lateral flow test before entry into the home was allowed.
There was an ample supply of PPE for staff and visitors to use. Hand sanitiser was readily available throughout the service. Staff had received additional training during the pandemic in the use of PPE and we observed staff wearing it correctly during the inspection.
Increased daily cleaning schedules were implemented including regular touchpoint cleaning.
People living in the home and their relatives were supported to maintain contact. The provider had installed an outdoor visiting pod so relatives could see their loved ones regularly. Indoor visiting was also facilitated.