Pathfinders Specialist and Complex Care

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment has remained good. This meant people’s needs were met through good organisation and delivery.

This service scored 64 (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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. While care plans and governance monitoring did not always record and reflect person centred care, people and their relatives consistently told us their experience was positive. People described a new initiative to help them to stay focused and motivated on their goals. One person said, “We work towards badges, for things like mini milestones. This can be for physical or social activities, whatever is relevant to each of us. I have 2 already and am working on the third.”

Relatives we spoke with consistently told us they were updated about people needs. A relative stated, “There is communication by phone and if [name] needs or wants or anything, they check with me. I feel involved. I get emails telling me how things are with [name].”

While the management team and staff understood peoples’ care provision, there were some shortfalls in how the provider recorded the diverse health and care needs of people and their local communities. We could not see or evidence that care was always joined-up, flexible or supportive of choice and continuity.

In addition to the lack of recording within care plans, people raised concerns with us about inconsistencies in care provided at the weekends specifically. One person said, “Nothing happens at weekends and there are definitely not enough staff to support me to go into the community.” Another person said, “Activities just stop at the weekend, and so do the interactions sometimes. I don’t feel seen at weekends, staff give me my medication and they I am virtually invisible.”

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs, however the recording of these were not always reflected within care plans. For example, 1 person was supported with a translator for a number of hours a day, however their communication care plan was not clear on how staff should support this person outside of this. Staff we spoke with were knowledgeable about people’s needs and could described the methods used, despite the lack of written guidance.

We fed these concerns back to the management team who took immediate action for those with communication barriers and formulated an action plan to ensure all care plans were reviewed.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result. Everyone we spoke with told us they knew how to raise a complaint and felt included in decision making. Where people had approached the registered manager with feedback or concerns they told us they received a timely response to their satisfaction. Some people said responses could be slower or inconsistent if concerns were raised with care and office staff, however stated they had not raised this as a further concern to anyone.

People and relatives, we spoke with could not tell us whether they had been asked for written feedback with methods such as questionnaires or formal care plan reviews, but most people confirmed staff and managers regularly checked in with them. One relative said, “I don’t remember a questionnaire and I’m not sure if there are relatives’ meetings or anything, but staff ask me if everything is ok and I get phone calls with updates, and they always check then too.” Another relative said, “I don’t sit down to review the care plan, but I know I can approach any staff member for help and support, I also know the manager is approachable and happy to receive feedback, [registered manager] is very good with that and really listens.”

The provider made sure that people could access the care, support and treatment they needed when they needed it. We saw evidence of people receiving timely access to services when needed such as GP’s. Due to the providers extensive therapy team which included occupational therapy, physiotherapy as well and speech and language therapy, people did not have excessive referral or wait times to have their care and support reviewed and commenced. People consistently praised the level of support received from these teams and stated they were adaptable to their needs. For example, 1 person said, “I was meant to have a physio session the other morning but I wasn’t feeling great so we moved it to the afternoon, I couldn’t have done this with an appointment at the hospital. It meant I didn’t miss anything, and I could do it when I would get the most benefit.”

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. Everyone we spoke with told us the culture of the home was open and inclusive. Staff told us they were supported with reasonable adjustments to enable them to return to work quickly and safely following periods of sickness. We saw evidence of appropriate risk assessments to support people and staff with personalised needs, including appropriate support for pregnancy, disabilities or care needs.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Care plans did not always contain details about people’s wishes or plans for their future care. It was not always clear from care plans whether these conversations had taken place. However, where needs and wishes had been recorded, this information was person centred and guided staff on how to support people and those important to them.