Pathfinders Specialist and Complex Care

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has remained the same. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Care planning was inconsistent throughout the home, where people were supported with therapies such as speech and language therapy or physiotherapy these aspects of care plan were detailed and person centred. People had clear goals and aims recorded which were regularly reviewed. However, where people had specific health conditions, such as diabetes or tissue viability risks, care plans did not always identify this or provide staff with guidance on how people should be supported. For example, one persons’ care plan stated that prior to any form of transfer or repositioning their blood pressure (BP) must be taken to ensure they were safe to be moved. However, the care plan did not state at what level the person’s BP needed to be in order for it to be safe to support their movement.

The provider did not always plan and deliver people’s care and treatment with them. Where peoples care plans had identified risks and needs such as repositioning and use of equipment such as bedrails, the care plans lacked clear guidance on how or when staff should support this. For example, several people required regular repositioning to prevent tissue damage to their skin, there was no guidance within the care plans on how often this should be completed. Daily notes showed staff supported people every 4 hours while at times there were intervals of 7-8 hours between repositioning. This meant people were at risk of harm from not receiving care that was in line with their wishes. However, where people required support with therapies such as physiotherapy or speech and language therapy care plans for this type of care were to a high standard and were person centred with peoples’ aims and goals clearly recorded.

The provider worked well across teams and services to support people. Professionals who worked closely with the service such as hospitals and the Local Authority gave positive feedback about their working relationship with the service. One professional said, “We as a team have had very positive outcomes with Pathfinders Neurological Care Centre and I personally feel that this is one of the best placements we have available for us to discharge our highly complex patients to. Pathfinders Neurological Care Centre are one of the few care homes who have experience to meet both medically and socially complex patients’ needs successfully and have always had positive feedback from patients who return to our unit for outpatient appointments following their placement there.” Another professional said, “Staff are regularly in touch and are forthcoming with questions which is helpful. We feel they take on board our recommendations and listen to suggestions. They are helpful and provide any information we need. Patients seem very well cared for.”

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. Although not always clearly documented, people were eager to tell us about the support and positive outcomes they had achieved whilst living at Pathfinders Neurological Care Centre. One person said, “I have hand therapy regularly, but I also go to the activities such as jewellery making and gardening. This helps me use my stiff hands and its fun.” Another person told us how they had built a friendship group and improved their social skill through activities and facilities provided at the home.

People told us the provider routinely monitored people’s care and treatment to continuously improve it; however, this was not always clearly documented. People and their relatives told us they experienced outcomes which were positive and consistent. One person told us about the support they had received to lose weight and improve muscle mass. Another person explained how they had been supported with their aims and goals in relation to the distances they were able to self-propel themselves in their wheelchair and how this had increased their fitness and level of independence.

The provider did not consistently support people and their relatives about their rights around consent to care and treatment and this was not always documented appropriately. However, people told us they received person centred care and staff always sought their consent prior to their care needs being supported.

Where people lacked capacity, the provider knew to apply the 2-stage test of the Mental Capacity Act which ensures people rights are protected. However, these assessments were not always completed or recorded appropriately. For example, 1 person’s care plan only contained stage 1 of the test and did not record who else had supported the person, such as relatives or other professionals. We consistently saw records where consent was being signed by a staff member without any justification for this having been done. This meant that people were at risk of not always being supported to understand their care and consent to treatment.

During the assessment we observed staff asking people for their consent prior to supporting them. People told us staff did this consistently. One person said, “I like the way they’re polite and ask me first if it’s ok to do something.”