Archived: The Pavillions

Updated 6 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

Inspection team

This inspection was undertaken by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was announced. We gave the service 72 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 17 May 2022 and ended on 17 June 2022. We spoke to people and their relatives by telephone on 20 May 2022 and we visited the office location on 17 June 2022.

What we did before the inspection

The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with three people who used the service, three relatives, a power of attorney and an advocate about their experience of the care provided. We received feedback from the local authority about safeguarding. We spoke with six members of staff including the registered manager, the care team leader, a senior care staff member and three care staff. We spoke to the chef who was a contractor. This is a person who undertakes a contract to provide a service or do a job.

We reviewed a range of records. This included four people's care records and medication records. We looked at one staff file in relation to recruitment, induction, training and staff supervision. A variety of records relating to the management of the service were also reviewed, including training records, incident records, compliments, quality assurance processes and policies.

After the inspection

We continued to seek clarity about the provider information return.

Updated 6 July 2022

About the service

The Pavillions is a domiciliary care agency that provides personal care support within an extra care housing scheme, to people in their own homes. The service supports older people some of whom are living with dementia, a sensory impairment, a physical disability and people with mental health support needs. The extra care housing scheme consisted of one building, that housed 40 one-or two-bedroom flats in Peterborough. At the time of our inspection there were 14 people using the care agency service.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

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

Staff used their training to safeguard people wherever possible and support people to keep them safe. If staff had any concerns about people, they knew where to report this. People received their medicines as prescribed and staff ensured they followed infection prevention guidance and good practise. Where people needed this assistance, staff helped people eat and drink.

Staff were caring and knew people’s individual needs and preferences well. Staff listened and respected people’s concerns and suggestions. Staff gave people privacy, treated them with dignity and respect when supporting them, and helped maintain people's independence. Staff involved people, their relatives, advocates and power of attorneys when reviewing people’s care. Staff were responsive to people’s changing care and support needs. Compliments about the service had been received. Complaints were investigated and resolved wherever possible and actions were taken to reduce the risk of recurrence.

Enough skilled and suitable staff had been safely recruited. The registered manager and the staff team took on board learning when things went wrong.

Staff knew people's individual assessed needs and risks. Care plans were reviewed and updated when changes occurred. Staff had received the required training, spot checks and ongoing support to help them maintain and improve their skills to fulfil their role and responsibilities.

Monitoring and oversight of the service was effective in identifying and driving improvements. The registered manager led by example and had cultivated an open and honest staff team culture. Audits were undertaken to monitor the service provided and the registered manager reported weekly to the board of directors to ensure organisational oversight was in place. The registered manager and staff team worked well with other organisations, health and social care professionals to provide people with joined up care.

People were supported to have maximum choice and control of their lives and staff supported in the least restrictive way possible and in their best interests.

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 under the previous provider was Good, published 30 June 2017. This service was registered with us on 01 July 2019 and this is the first inspection.

Why we inspected

This inspection was based on the service being unrated under its current provider's registration.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.