• Residential substance misuse service

The Pavilion

Overall: Good read more about inspection ratings

Ashton Road, Lancaster, Lancashire, LA1 5AZ

Provided and run by:
Delphi Medical Limited

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Pavilion 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 The Pavilion, you can give feedback on this service.

8,9 January 2019

During a routine inspection

We rated The Pavilion as good because:

  • Staff risk assessed clients and reviewed how they managed these risks daily to keep clients safe. Medicines were managed safely. The premises were safe, clean well equipped, well furnished, well maintained and fit for purpose.
  • There was a commitment to interagency working with good working practices with GPs commissioners, the police and the local accident and emergency department.
  • All clients had access to a group programme and one to one sessions to help them understand and manage their addictions. The service was organised to meet clients’ needs. Care and treatment was coordinated with other providers.
  • Clients were supported, treated with dignity, respect and compassion.
  • Staff helped clients prepare for discharge and ongoing support was offered through a weekly aftercare group. They sought and involved carers and family members when appropriate.
  • The governance structures within the organisation functioned effectively with clear visions and values.


  • Care plans were not fully personalised.
  • Clients did not have a named key worker.
  • Of the three records we looked one out of three did not contain a risk management plan and plans were not comprehensive.
  • Supervision levels had not been fully completed in line with the organisations policy. Levels had significantly improved over the last two months before inspection and staff reported they were well supported.

23 to 24 October 2017

During a routine inspection

We do not currently rate independent standalone substance misuse services.

We found the following areas of good practice:

  • The service had enough staff to care for patients and their level of need. Staff knew and put into practice the service’s values, and they knew and had contact with managers at all levels.

  • Care plans and assessments were holistic, recovery-orientated and included clients’ views. All clients had comprehensive risk assessments completed. Clients could access a comprehensive therapy programme as part of their treatment. Clients’ physical healthcare was monitored throughout their stay. Staff supported clients to plan for discharge. Outcome measures, treatment and assessment scales were in place to assess and monitor client’s treatment and fed into the national drug treatment monitoring system.

  • The service followed national institute for health and care excellence guidelines when prescribing medication to ensure best practice in detoxification and withdrawal were implemented.

  • Staff had received an annual appraisal of their work performance and regular managerial and clinical supervision.

  • The use of shared care records was innovative as clients were able to access, input and read their records at any time using an electronic recording system. They were provided with their own password to enable them to access their care records from the service both during and after treatment. They were able to document their own thoughts and views directly into on their own care records.

  • Clients were treated with kindness, dignity and respect. Clients told us that they felt listened to and staff knew their individual needs well. The diverse needs of clients were accommodated across all aspects of the service. Clients had the opportunity to give feedback about their care and treatment. Clients using the service were fully involved in their care and treatment.

  • Clients were protected and safeguarded from avoidable harm and incidents were appropriately reported. There was an open and transparent culture within the Pavilion. Staff was aware of the provider’s incident reporting and complaints processes.

  • The service was well led by the manager and the organisational management team. There was a clear commitment towards continual improvement with an improvement plan in place.

    However, we also found the following issues that the service provider needs to improve:

  • The provider did undertake prescription chart audits however, this was done without the use of a standardised audit tool for consistency. Nursing staff were signing for medicines prescribed for self administration, which did not correlate with the policy. On some prescription charts, medicines were prescribed with two doses available, with no space to identify which dose was given. We also saw some charts where doses had been overwritten when a dose was changed, rather than re-written, increasing the risk of the wrong dose being administered.

  • The overall percentage of staff having completed their online mandatory training was 61% and this should be continued to be delivered and monitored.

  • The provider should review out of hours on call provision and consider the need for medical provision.