Pavilion Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand what being safe meant to them and protected them from abuse, avoidable harm and neglect. They shared concerns appropriately and worked effectively with partner agencies to keep people safe. Safeguarding systems provided leaders with oversight of concerns, investigations and outcomes. Staff understood safeguarding procedures and knew how to raise concerns. Care records showed staff followed the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, including recording best interests decisions and authorised restrictions. Staff shared learning from safeguarding concerns to improve practice. One person told us, “Staff would sort it out if I didn’t feel safe, they make me feel safe.”

The provider worked with people to understand and manage risks in a way that enabled them to remain as independent as possible while keeping them safe. Risk assessments and care plans were detailed, person-centred and regularly reviewed. People's risks, including falls, choking, skin integrity concerns, feeding tubes and behaviours of distress, were clearly identified and supported through appropriate guidance for staff. Records demonstrated involvement from people, relatives and healthcare professionals when reviewing risks and deciding how risks should be managed. A relative told us, “Any concerns are dealt with, I am included in professional meetings and if any risks are changed, I am informed.”

The provider detected and controlled risks within the care environment and ensured equipment, facilities and technology supported the delivery of safe care. The environment was clean, well maintained and we found no significant environmental hazards. The provider checked fire safety arrangements, equipment, window restrictors, secure storage and emergency evacuation systems. Audits identified areas requiring attention and leaders took prompt action to address issues, demonstrating effective oversight of environmental safety.

The provider ensured there were enough qualified, skilled and experienced staff to meet people's needs safely. Staff received appropriate support, supervision and development. Records showed staffing levels met or exceeded those identified through dependency assessments and agency use was minimal. Recruitment processes included the required pre-employment checks. Staff received regular supervision, competency assessments and training. Training records showed most staff had completed mandatory and role-specific training. Staff demonstrated knowledge of risks, safeguarding procedures and people's individual support needs.

The provider assessed and managed the risk of infection and took action to prevent and control the spread of infection. The environment, including bedrooms, communal areas and equipment, was clean and hygienic. Staff followed infection prevention and control procedures, including hand hygiene and appropriate use of personal protective equipment. We observed improvements to the environment since the previous assessment, including replacement handrails, removal of carpets and refurbished bathrooms, which supported effective infection prevention and control. Audits, cleaning schedules and action plans provided assurance that infection prevention systems were effective and that previous concerns had been addressed and sustained. One person described the home as “spotless” and said, “The cleaners do an excellent job.”

The provider ensured medicines and treatments were managed safely and met people's needs, capacities and preferences. Medicines were stored and administered safely and in line with best practice guidance. Records reviewed were complete and accurate, and checks of medicines requiring additional security and monitoring were correct. Staff responsible for medicines had received appropriate training and competency assessments. Medicines audits and governance systems identified issues promptly and supported ongoing oversight.