Inspection on 28/01/10 for Pavilion Court

This inspection was carried out on 28th January 2010.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pavilion Court 23/11/09

Pavilion Court 11/02/09

Pavilion Court 16/05/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Random inspection report Care homes for older people Name: Address: Pavilion Court Brieryside Cowgate Newcastle Upon Tyne NE5 3AB one star adequate service 24/11/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lee Bennett Date: 2 8 0 1 2 0 1 0 Information about the care home Name of care home: Address: Pavilion Court Brieryside Cowgate Newcastle Upon Tyne NE5 3AB 01912867653 01912865794 pavilioncourt@cshealthcare.co.uk www.southerncrosshealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross BC OpCo Ltd care home 75 Number of places (if applicable): Under 65 Over 65 0 75 dementia old age, not falling within any other category Conditions of registration: 75 0 The maximum number of service users who can be accommodated is: 75 The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 75 Dementia Code DE, maximum number of places 75 Date of last inspection Brief description of the care home Pavilion Court is a 75-bedded care home situated in the Cowgate residential area of Newcastle. The home opened in August 2005 and provides residential and nursing care to older people over two floors, including those with dementia care needs. All bedrooms are single and have en-suite facilities. There is a range of communal space Care Homes for Older People Page 2 of 11 2 4 1 1 2 0 0 9 Brief description of the care home including seven dining rooms and lounge areas. The home is attractively decorated and furnished. A range of aids and equipment has been provided. People who use wheelchairs can access all areas of the home. Off road parking is available and the home is close to local bus routes. Fees for the home vary. Further information about fees can be found in the homes statement of purpose and service user guide. A copy of the last inspection report has been appended to the service user guide a copy of which is available in the main reception area. Care Homes for Older People Page 3 of 11 What we found: We undertook this inspection to follow up requirements made at a previous inspection. We looked only at those requirements that have now become due to be completed. Previously made recommendations were not examined as part of this inspection. Requirements that were made previous to the inspection of February 2009 Requirement 1. Ensure that all staff follow the medicine procedure when administering medication. Residents are fully supervised to ensure they take all of their medication. Staff responsible for the handling of medicines in the home have received training and observed competency testing to ensure they follow safe procedures for the administration of medicines. We looked at an example of the assessors observations, and saw that these were comprehensive and identified areas for further action. We saw no instances were service users were given medicines and then not observed to take these. This requirement has now been addressed. Requirement 2. Provide all staff with training in the protection of vulnerable adults. This helps to protect residents from abuse. Staff have now received training on abuse awareness and adult protection. This requirement has now been addressed. Requirement 3. Address the cause of the odours in the home. Provide bins that are foot operated. This helps to ensure that the home is hygienic and pleasant for residents to live in. We undertook a tour of the home. We observed no persistent unpleasant odours in the home. This requirement has now been addressed. Requirement 4: Proved a training action plan indicating the timescales for meeting training targets. This promotes better standards of care for residents. A review of what training has been undertaken by individual staff has been carried out. From this review a training programme has now been developed. This requirement has now been addressed. Care Homes for Older People Page 4 of 11 Requirement 5: Ensure that all health and safety checks are brought up to date and continue to be checked at the correct intervals. We examined a range of records associated with the health and safety checks carried out by the manager and maintenance staff. Evidence is contained within bound record books that are used on a company wide basis. Areas such as hot water safety test, electrical safety and falls analyses are carried out on a regular basis. This requirement has now been addressed. Requirements made on 07/07/09 Requirement 1. Levels of care and supervision in areas where people with dementia live need to be improved. This is to ensure the safety and welfare of the people here. We spent some time looking around the home, and observing the level of staffing input provided for the people living here. We saw that staff are now more actively engaged in offering activities, and will now share their own meals with service users at meal times. The manager is also looking at what paperwork staff are being asked to complete, and trying to reduce the amount undertaken that is unnecessary or repetitive. This means that staff are more able to spend time observing, interacting and assisting service users. This requirement has now been addressed. Requirement 2. Medication recording must be completed contemporaneously, and eye drops dated when opened. This is so medication is always safely handled and error minimised. We examined medication recording and storage arrangements in two separate areas of the home. We found that in one, eye drops were dated at the time of opening. In the other this was not the case. However, the date of supply for the eye drops was within 28 days so these eye drops remained in date. Nevertheless, it is good practice to date all eye drops, and other medication products with a defined shelf life upon opening. This will help ensure that service users do not receive out of date medicines. We also examined the administration records for the medicines administered at the most recent medicine round. These were fully completed. We did however observe a gap in the record for a medicine that had been omitted several day prior to our visit. This was highlighted to the manager to follow up. A new requirement has been generated regarding this. This element of this requirement relating to recording has been addressed. The element relating to eye drops has been downgraded to a recommendation as the eye drops concerned were still in-date. Care Homes for Older People Page 5 of 11 Requirement 3. A range of activities and occupation needs to be provided. This is to ensure the people staying here are offered opportunities to be engaged and stimulated in a meaningful way. We spent some time observing life in the home. We saw that staff are now more actively involved in providing both group and one to one activities and occupation with the people living here. We saw several people taking part in a manicure session. Staff were also encouraging people to help with chores around the home. Furthermore, we were told about the activities people were involved in, including trips out of the home. There have been visits from a patted dog scheme, and a school choir visited over Christmas. There is now a dedicated activities co-ordinator employed here, but the manager is encouraging all staff to see this as an integral part of their role. She sees this area as work in progress, but we are encouraged by the progress already made, and the increased focus on this aspect of life in the home. We feel there has been sufficient progress to remove this requirement, but will keep this area under review as we continue to inspect the home. Requirement 4. The actions taken and outcome of all complaints must be clearly documented and a summary fed back to the complainant. This is so everyone can be confident that their views are listened to and acted upon. We examined the record of complaints made to the home since 24th November 2009. We saw that the manager maintains a complaints register. This contains a summary of the complaint received, and offers a brief summary of the actions taken. A more detailed record for each complaint is also kept. Here the complaint is detailed (and relevant correspondents kept), an acknowledgment provided to the complainant, and later on an outcome letter provided. A log sheet is completed that details the complaint, the findings of the investigation, the corrective action taken, and considerations for future action. This requirement has now been addressed. Requirement 5. Arrangements for the reporting of suspected abuse must be effectively implemented and the Local Authority (Social Services) must be informed of alleged incidents or suspicions of abuse without undue delay. This is so people are protected as far as possible for unnecessary harm. We reviewed this information we have received since we last inspected the home. We also looked at the evidence kept here. We found that where it is suspected that people may be at risk of harm, the local authority is alerted to this. This is in line with local reporting procedures. This requirement has now been addressed. Care Homes for Older People Page 6 of 11 Requirement 6. Staff need to be deployed in sufficient numbers to ensure at least adequate supervison and engagement on the units for people with dementia. This is so people can be kept safe and be given opportunities to lead a fulfilling life. Please refer to the comments above, regarding requirements 1 and 3. This requirement has now been addressed. Requirement 7. Visits required under regulation 26 must be conducted at least monthly, with records kept at the home. This is so the operation of the home, and welfare of the people living here is subject to regular scrutiny. The line manager for the home visits here regularly. As part of these visits she also carries out formal inspections. A record of these is now kept, with a copy left with the homes manager. This is so that she is made aware of areas that require attention, and these can be followed up at subsequent inspections. This requirement has now been addressed. Requirement 8. Record keeping arrangements must ensure that they are stored for the required period, and can be readily and efficiently retrieved. This is so peoples confidences can be assured. The manager is currently working with the senior staff team to archive old records. This is currently work in progress. Nevertheless, all of the records that we requested were provided to up promptly. We feel there has been sufficient progress to remove this requirement, but will keep this area under review as we continue to inspect the home. What the care home does well: - The people living here are being provided with an increased range of activities and occupation. - Staff are less task orientated. - Peoples views are listened to and complaints clearly recorded. - The home is clean and fresh. - Staff training is well planned. - The home is regularly inspected by a line manager. Care Homes for Older People Page 7 of 11 - Health and safety is regularly checked. - There is a permanent manager employed here. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 11 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 9 of 11 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medicines must be 19/04/2010 administered to service users as prescribed. This is so service users health is promoted. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Staff should make sure eye drops are dated upon opening. Care Homes for Older People Page 10 of 11 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. 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