Pavilion Court

Pavilion Court is a residential care home providing personal and nursing care to up to 75 people. The service provides support to people aged 18 and over, some of whom were living with a dementia. At the time of our inspection there were 48 people using the service.

People’s experience of using this service and what we found

People were at risk of harm as staff were not following the provider’s risk assessments or procedures. We found where people were identified at a risk of choking or were required to follow a special diet, food and drinks were easily accessible. Staff had not removed all health and safety risks which placed people, who may not have had the capacity to make safe choices, at risk of potential harm.

Risk assessments were in place and these were reviewed by the manager and regional manager. The quality and assurance systems in place were generally effective to monitor the safety and quality of the care provided but were not fully effective for medicines management.

Medicines were not always managed safely. People’s records did not include all of the details of medicines administered. Topical medicine records showed patches were not always administered as prescribed. Management audits had highlighted the issues with medicine administration but did not highlight all areas of concern.

People had personalised care plans in place which detailed their own choices and preferences. Staff worked in partnership with other healthcare professionals to make sure people had all of their needs met. There was enough qualified staff to safely support people.

People were observed to be happy living at the home and interacting positively with each other and staff. People were supported to be as independent as possible.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 July 2019).

Why we inspected

We received concerns in relation to the safety of care provided to people. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pavilion Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management and medicines management at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. 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.

¿ The home was clean and there was regular cleaning of all surfaces. The environment had been refurbished and furniture was used to support with social distancing.

¿ Professional visitors completed health declarations and were tested for COVID-19 at the service. Risk assessments were completed prior to each visit.

¿ Staff wore appropriate Personal Protective Equipment (PPE) and had access to this throughout the home. Staff had received additional training during the pandemic about correct PPE usage and infection prevention and control.

¿ The registered manager and staff had carried out fund raising activities during the pandemic to purchase a large table e-tablet to enable people to stay active, socialise and stay in contact with their relatives.

¿ There was a designated visiting room at the home which allowed for risk assessed visiting between people and their relatives when restrictions allowed.

Pavilion Court is a residential care home providing personal and nursing care to 39 people aged from 18 and over at the time of the inspection, some of whom were living with a dementia. The service can support up to 75 people in one large adapted building.

People’s experience of using this service and what we found

Environmental risks had not always been identified and assessed, and we have made a recommendation about this.

There were quality and assurance systems in place to monitor people’s safety and care. The management team completed audits to improve the quality and safety of the service.

People and their relatives were positive about the care and support provided by staff. People received person-centred care from staff who knew them well. The service worked in partnership with other health and social care agencies to provide responsive and continuous care to people.

Medicines were managed safely and in line with best practice. Individual risks to people had been assessed and mitigated to help keep people safe. There were regular reviews of people's needs to make sure they received the support they required. People had regular input from other health care professionals and external agencies, for example GPs.

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.

Staff respected people's privacy and dignity at all times. People were supported to engage in activities which were of interest or benefit to them.

Staff were recruited safely; they received regular support and training. New staff were provided with a comprehensive induction which provided them with the relevant knowledge and skills for their roles.

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

The last rating for this service was requires improvement (published 05 December 2018) and there were multiple breaches of the regulations. At this inspection, a new manager was in place and we found that robust action had been taken to improve.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the service had made sustained improvements and addressed the initial issues identified at the last inspection.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor the service through information we receive from the service, provider, the public and partnership agencies. As part of our process we will be meeting with the provider to discuss how the service will build on the improvements in place. We will re-visit the service in line with our inspection programme. If we receive any concerning information we may inspect sooner.

At this inspection we identified a number of concerns and shortfalls which resulting in a breaches of regulations 9 (person centred care), 10 (dignity and respect), 12 (safe care and treatment), 17 (good governance) and 18 (staffing).

The provider had not adequately assessed the risks to the health and safety of people using the service, staff did not provide person centred care, staff demonstrated unsafe practice, people were not always treated with dignity and respect, people’s support needs were not met, staffing levels were not adequate to meet people’s needs and the governance of the service did not fully assess the quality of the care provided. During the inspection we raised four safeguarding alerts to the local authority due to concerns about the standard of care people were receiving. Following our site visit we also received additional whistleblowing concerns which we also shared with the Local Authority Safeguarding team.

You can see the action that we have asked the provider to take at the back of the full version of this report.

Pavilion Court is 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Pavilion Court can accommodate 75 people in one adapted building and on the date of this inspection there were 56 people living at the service. People received a mixture of residential and nursing care. Some people living at the home had a diagnosis of dementia or had fluctuating capacity.

Staff had received initial training around safeguarding vulnerable adults’ but we noted that this training had not been refreshed or completed by the majority of staff. Staff had received supervision sessions around safeguarding and could tell us what action they would take if they were concerned or witnessed any form of abuse. People told us they felt safe living at Pavilion Court Care Home and relatives agreed with these comments. There were policies and procedures in place to help keep people safe from abuse, these included the provider’s safeguarding vulnerable adults’ policy and information for people and relatives about reporting abuse.

We observed and were told by people that there were not always enough staff to support people when needed. The service assessed dependency needs for people which we reviewed as well as the staffing rotas for four weeks. The service frequently used agency staff but this had begun to reduce as new staff had been employed by the service. We observed that staffing levels on the second day of inspection were appropriate to support people. Staff, people and residents told us that at times there were not enough staff to support them, especially at night.

Staff did not always treat people with dignity and respect. We found records of people’s daily care in communal areas. Some people told us that they did not always know who was supporting them and that they did not receive the support they needed, when they needed it. Some people told us the staff spoke nicely to them and were caring. We observed people enjoyed positive relationships with some staff. We saw staff asking people for consent when supporting and asking for people's choices for meals and drinks.

There was an infection control policy in place at the home but this was not always followed by staff. Communal lounges and dining rooms were not clean. We saw housekeeping staff cleaning people’s bedrooms and communal bathrooms.

The home did not provide safe medicine management. Care plans for ‘as required’ medicines were not completed or absent from people’s care records. Procedures were in place to provide guidance on the receipt, storage, administration and disposal of medicines. There were records regarding other professionals involved in people's care. People's medicine care plans completely documented all the information needed to fully support people.

During the inspection we found that the premises were not always safe for people living at the home. The sluice room on the ground floor was open because the key pad lock was not working, the clinical waste bins were open and unlocked, and kettles containing boiling water were left on benches in areas where people could not fully assess the risk to themselves.

People were supported to maintain a balanced diet. However, people did not have access to a range of foods and fluids throughout the first day of our inspection, but we noted that there were different fluids and foods available on the second day of inspection. Food and fluids were easily accessible to people who could not make safe choices or who were at risk of aspiration and choking or who had special dietary requirements. These risks had not been identified or mitigated at the time of our inspection. People and relatives had mixed comments about the meals provided. Some people told us they liked the food and others told us that there was not much choice.

Staff received regular supervisions from the new registered manager and these included lessons learned from safeguarding incidents, complaints, best practice and accidents/incidents. Staff received a thorough induction from the provider before working within the home. Most staff training was out of date and the registered manager had arrangements in place to ensure that all staff received the mandatory and additional training sessions applicable to their role for the week after our inspection. Agency staff also received an induction from the provider before working at the service.

Most people had personalised risk assessments in place to keep them safe. People had care plans in place for general things, for example personal hygiene, mobility and sleeping and individual plans for specific things, such as, being unable to use the call bell. We noted that some care plans were illegible and the general care plans were very standardised. People, relatives and external health professionals were all involved in best interest decisions and mental capacity assessments. However, people's care records were not always accurate and up-to-date.

There was a new registered manager in post who had been registered with the Commission to provide the regulated activity since October 2018 and had worked at the service for approximately two months, this was one of the requirements of the home's registration with CQC. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Accidents and incidents were recorded correctly and if any actions were required, they were clearly documented and addressed. Lessons learned were shared with people, relatives and staff. Where appropriate, the registered manager had escalated these to the local authority as a safeguarding concern and notified CQC.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Most staff demonstrated their understanding of the MCA.

People and relatives knew how to raise a complaint or concern. There was information on how to make a complaint displayed within the service and this was accessible to everyone. Feedback was sought from people, relatives, staff and visitors to help continuously improve the service.

The management team had a clear vision to care for people living at the home and had plans in place to improve the quality of care provided to people. Staff told us that they were fully supported by the registered manager and were positive about the changes that they had introduced. Relatives said that they were always welcomed at the service and commented that the new manager took time to speak to them.

The registered manager and deputy manager carried out checks and audits of the service but these were not always documented or identified the issues we had identified. The provider did have a governance framework in place to monitor the quality and assurance of the service but this did not highlight all the issues we identified.

There was a new activities coordinator in post who was introducing a range of meaningful activities for people. We observed activities being carried out with large groups and in a one to one setting during the inspection. The service promoted advocacy and there was accessible information available detailing what support people could access to help make choices about their individual lives.

The service provided end of life care to people and the service was working with a partnership agency to provide palliative care in a designated unit at the home.

The premises were ‘dementia friendly’ and there was pictorial signage to help people orientate themselves. The communal areas of the home needed some refurbishment and the registered manager told us about plans already in place for this. People had personalised bedrooms.

We last inspected the service on 24 and 30 August 2016. We identified two breaches of our regulations. These related to person centred care and good governance. We asked the provider to take action to make improvements and this action has been completed.

At this inspection, we found that improvements had been made and the provider had ensured good outcomes for people in each of the five key areas we inspected. Pavilion Court provides care and accommodation for up to 75 people, some of whom have a dementia related condition. There were 41 people living at the home at the time of the inspection.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People, relatives and staff were positive about the changes the registered manager had implemented. Staff informed us they were happy working at the home and morale was good. We observed that this positivity was reflected in the care and support which staff provided throughout the day.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. There was one ongoing safeguarding allegation which the registered manager was investigating.

An electronic medicine system was in place to manage medicines. There had been a number of medicines errors prior to our inspection. The registered manager had fully investigated these and was liaising with their pharmacy supplier. Several people had certain medicines administered via a patch applied to their skin. A system was in place for recording the site of application. It was not clear however, that one person’s patch application had been rotated in line with the manufacturer’s guidance.

We have made a recommendation that the provider follows best practice in relation to medicines management to ensure people receive their medicines as prescribed and in line with manufacturer’s guidelines.

We spent time looking around the premises and saw that all areas of the building were clean and well maintained. There was a lack of storage space in some of the ensuite bathrooms we viewed.

Safe recruitment procedures were followed. Some people told us that more staff would be appreciated. We observed that staff carried out their duties in a calm, unhurried manner on the days of our inspection.

The registered manager provided us with information which showed that staff had completed training in safe working practices. Evidence of nurses’ clinical skills and competencies was not always available. The registered manager told us that this was being addressed. We did not have any concerns about the skills of nursing staff.

People received suitable food and drink to meet their needs although menus did not always reflect best practice guidelines.

We observed positive interactions, not only between care workers and people, but also other members of the staff team. End of life care was delivered in line with evidenced based practice.

An activities coordinator employed to help meet the social needs of people. A varied activities programme was in place.

There was a complaints procedure in place. Feedback systems were in place to obtain people's views. Meetings and surveys were carried out.

A number of checks were carried out by the registered manager. These included checks on health and safety, care plans, infection control and medicines amongst other areas.

Our observations and findings during the inspection confirmed there was now an effective quality monitoring system in place.

Pavilion Court is a care home which provides nursing and residential care for up to 75 older people, including people living with dementia. There were 42 people living in the home at the time of this inspection.

The service did not have a registered manager. The registered manager had left since our previous inspection and although a new manager was in post they had not applied to become the registered manager at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were kept safe from harm. Staff were aware of the different types of abuse people might experience and of their responsibility for recognising and reporting signs of abuse. People and their relatives told us they felt safe.

Staffing levels were calculated based on dependency levels and expected staffing ratios. They were reviewed on a monthly basis and on paper appeared appropriate. However during the inspection we observed there were not sufficient staff to provide people with the assistance they required promptly. We have made a recommendation about this.

Possible risks to the health and safety of people using the service were assessed and appropriate actions were taken to minimise any risks identified. People were assisted to take their medicines safely by staff who had been appropriately trained.

Staff were not always provided with sufficient information to enable them to administer topical medication effectively. Clear records were not being kept of the reasons for non-administration of this medication. We have made a recommendation about this.

Staff had been provided with regular training and support to assist them in performing their roles effectively.

Care plans we viewed were evaluated on a regular basis but not always updated in a timely manner. There was limited evidence of people and their family members being involved in care planning. The manager had already recognised this and started to take action to resolve this through working with other staff members to develop a process for reviewing all care plans in conjunction with people and their family members.

The service had not regularly sought feedback from people about the service. This was something the manager had identified and was taking action to resolve at the time of the inspection.

The provider’s complaints policy and procedure were very prescriptive and although the complaints we viewed had been dealt with appropriately we found these had not been responded to in accordance with the provider’s policy and procedure. We have made a recommendation about this.

The service did not have a permanent team of qualified staff in place to support people. People, their friends and family members and external healthcare professionals told us this meant the care people received was not always consistent. The manager was already aware of this issue and had taken steps to recruit permanent qualified staff and reduce agency usage.

The service did not have an activities programme in place. During the inspection we saw limited evidence of activities for people using the service. People we spoke with told us they did not always receive support to maintain their hobbies and interests.

The manager had only been in post since May 2016. Staff spoke positively of the impact she had on driving improvement in the service although they told us they did not always find her approachable and would like her to get more involved with staff on a one-to-one basis.

The provider had a range of systems in place for monitoring and reviewing the service, however, we found these were not always fully effective at addressing and resolving issues. We found care documentation was not always being fully completed or updated in a timely manner and there was limited evidence of people or their relatives being involved in care planning. There was a lack of permanent qualified staff and as a result the care and treatment people had received had not been consistent. Limited engagement had been undertaken with people or their relatives in order to obtain feedback about the service and make improvements.

We found breaches of Regulations relating to person-centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People's needs were fully assessed and their care was planned to provide safe and effective care. A member of the management team was available on call in case of emergencies.

People and relatives we spoke with told us they felt safe in the home and well-protected by staff. One person said 'I have no worries here. I'm not forced to do anything.'

Systems were in place for checking safety equipment and systems such as fire alarms and hot water temperatures.

The numbers and deployment of staff were not sufficient to meet all the needs of the people living at the home, particularly their social needs.

We found evidence that indicated the home did not always accurately identify, or respond appropriately to, safeguarding issues. This is being followed up and we will report on any action when it is complete.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We found that people were having limits put on their liberty but that no applications had been submitted for approval by the local authority. This is being followed up and we will report on any action when it is complete.

Is the service effective?

Most people told us that they were happy with the care that had been delivered and their needs had been met. Our observations and our discussions with staff showed that they had a good understanding of the people's care and support needs and that they knew them well. One person told us, 'I'm quite happy here. I'm well looked after, and the food's good.' A visiting professional told us, 'The home is able to provide effective care outcomes for its residents.' A second professional said, 'It's a very good care home, they deal very well with patients with dementia.' Other professionals felt people living with dementia would benefit from extra mental health nurses, due to the complex needs of people living in the home.

Most relatives we spoke with said their relative was receiving appropriate care and that their needs were met. One told us, 'The staff are excellent. Our relative has improved mentally and physically since moving into the home.' However, some felt that although staff were dedicated and caring, they did not always have time to meet all people's assessed needs.

Staff had not received all the training necessary to meet the needs of the people living at the home. Staff were not being given appropriate supervision and appraisal of their work. Systems to promote people having adequate food and drink were not always working properly. We have asked the provider to tell us how these issues will be addressed.

Is the service caring?

People were supported by kind and attentive staff, who showed patience and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person said, 'The girls are lovely, really nice and caring.' A relative commented, 'The staff are overworked but very caring and helpful. There are instances of very good care.' A visiting professional told us, 'I believe the staff care about their residents.'

Is the service responsive?

People's needs had been assessed before they moved into the home. People told us they had been asked for their wishes about their care and these had been recorded. Records confirmed people's preferences, interests and needs had been recorded and care and support had been provided in accordance with people's wishes. One person told us, 'I just have to ask and they'll do it.' A relative told us, 'They get the doctor, when needed. We can raise anything, and they keep us informed.' Another relative told us, 'The staff are very good. They keep us informed, and ring us if they have any concerns.' A visiting professional told us, 'Staff listen to advice and take it on board.'

People did not have full access to activities that were important to them, and had few opportunities to leave go out into the community.

A number of staff and some relatives felt the management of the home was not responsive to issues raised. Not all complaints and concerns had been recorded or responded to properly. We have asked the provider to tell us how this issue will be addressed.

Is the service well-led?

Staff had a good understanding of the ethos of the home, and took a pride in their work. Staff told us they were clear about their roles and responsibilities.

Opinions on the management of the home were mixed. Visiting professionals told us the manager was responsive and co-operative, and ensured her staff followed advice given. Some staff felt the home was well-managed, and the manager was visible and approachable. Other staff felt the management of the home was not open and responsive, and did not support staff.

Quality assurance processes were in place but were not fully effective. People who used the service had not been asked for their views about their care and treatment for nearly two years, so we could not be sure their views were acted upon. Staff were not asked for their views on the running of the home. We have asked the provider to tell us how this issue will be addressed.

The provider had not notified the Commission of allegations of abuse, nor of an incident reported to and investigated by the police. This is being followed up separately and we will report on any action when it is complete.

We found the management of the home had failed to establish a culture whereby people, their relatives and staff felt they were listened to.

Improvements had been made to the quality of the records kept regarding people's medicines; and storage of confidential records made more secure.

Some people who used the service had complex needs which meant they could not share their experiences. We used a number of methods to help us understand their experiences, including carrying out an observation, speaking with people who could share their experiences and speaking with visiting relatives.

During our observation we saw people were treated with consideration and respect. Relatives told us they were happy with the care which was provided. One relative said, "I've been very impressed with the staff, they deserve a medal. Usually my mum isn't really interested in food. But she's been eating well since she's been here and she's managed to put on weight."

We reviewed six care records and saw that people's preferences and care needs had been well documented. Staff were knowledgeable about the people's care needs and what they should do to support them.

There were enough staff to meet people's needs and appropriate arrangements were in place to manage medicines.

However we saw that care was provided in an environment that was not adequately maintained and records were not kept securely.