Pavilion Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation relating to good governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good-quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Governance systems included regular audits of the environment, infection prevention and control, medicines, care planning, safeguarding and incidents. Leaders maintained oversight through regional manager visits, quality assurance reviews and action plans, with completed actions monitored through service improvement systems.

Audit findings reflected the conditions observed during the assessment and there was evidence actions identified through audits had been completed and followed up. Improvements previously required in relation to governance, infection prevention and control and the environment had been embedded into practice, with no evidence of repeat concerns. A relative told us, “Since the new manager has taken over, the home has improved significantly.” One healthcare professional told us, “Staff attentively listen, appreciate external perspective and recommendations, and follow these through accordingly.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.