Pathfinders Specialist and Complex Care

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of the legal regulations relating to safe care and treatment, person centred care and staffing. We have asked the provider to take action to make significant improvement.

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Where incidents had happened and staff had completed incident forms, the management team had consistently not reviewed these forms to identify any potential ongoing risk to people. This meant opportunities to improve peoples standard of care and share lessons learned had been missed. We saw audits from other professional visits such as the Local Authority which had raised areas for improvement. However, many of these identified issues remained on the assessment, this showed the provider did not prioritise or develop a learning culture.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The provider had an admission check list that guided staff in what documentation needed to be completed and by what timeframe when someone was admitted to the home. As per this process a person should have a care plan developed within 48 hours of being admitted to Pathfinder Neurological Care Centre to ensure people received safe care following their transition. However, this process was not always followed. For example, one person who had been recently admitted to the home had not had risk assessments completed or a full care plan developed after 8 days. This placed them at risk of harm from receiving unsafe care or care not in line with their wishes.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. The provider had a safeguarding log; however, not all incidents had been identified and recorded on this log which resulted in CQC and the Local Authority not being notified in line with requirements. This meant that people were placed at the risk of harm from potential unidentified abuse or neglect. Staff told us they received training in safeguarding as well as regular refresher training and had access to the providers safeguarding policy.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, one person did not have a communication plan to support staff despite being nonverbal and English not being their first language. Staff had created ways of communicating such as the use of a tablet computer to aid translation and by speaking with family to understand the persons communication style, but this was not clearly documented. We spoke to the provider who took immediate steps to develop this support plan. People and relatives we spoke with told us they were not routinely included in care planning or reviews. One person said, “I have had loads of meeting about my care with the multi-disciplinary team which has been good, but I don’t know if that’s in my care plan I have never seen it.” A relative said, “They do ring me with updates, so I just presume the care plan is updated?”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, some rooms that were open and accessible to people contained harmful chemicals, such as detergents and aerosols. We also found on the assessment some fire doors did not meet the required specification and had damaged seals or holes within them. This meant that in an event of a fire the fire doors would not prevent the spread of fire as intended which placed people at risk of harm. We raised these concerns with the provider who undertook an immediate audit and developed an action plan to ensure the environment was brought up to a safe level.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. Despite the environment appearing calm and call bells being responded to promptly on the days of the assessment, most people we spoke with raised staffing as an issue. One person said, “We know when they’re short, staff are upset. It can be really bad on nights. They seem to lose a lot of them. Staff tells us that management doesn’t have their back and retention of new starters is bad. We’re told not to befriend staff. I just need people to care about me. It’s fantastic for the physical side of things but not so much for our mental health and emotional well-being.” While another person stated, “They can be short [staffed] quite often as it takes longer to be seen to at times,” A relative we spoke to also commented that, “I do quite often have to hunt for a carer, if I need someone to assist [Name]. It’s even more of a challenge at the weekend. That does concern me.” Some staff we spoke with gave similar feedback, one staff member said, “It can be challenging at times at which point therapy and rehabilitation care is always sacrificed.”

Records showed at times people were supported with care in which staff had not been trained in. For example, we saw records that showed 2 staff members has supported a person with PEG feeding and flushes without appropriate training. PEG (Percutaneous Endoscopic Gastrostomy) feeding is a method of providing nutrition, fluids, and medicines directly into the stomach through a tube inserted through the abdominal wall. It is used when individuals are unable to eat or drink adequately to maintain their nutritional needs.

We spoke with the management team about the feedback we received and concerns about training and asked the provider how they ensured safe staffing levels. The management team could not evidence how staffing levels were calculated and did not use tools such as dependency tools to support this decision-making process. The provider advised they would review this as a matter of urgency.

Recruitment of staff was done safely and with appropriate checks such as references and disclosure and baring checks undertaken prior to staff commencing employment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Room checks identified issues with deep cleaning not being regularly undertaken. Unclean equipment was stored in people’s rooms, such as wheelchairs which were visibly dirty and contained food debris. Several communal bathrooms and ensuite bathrooms had infection, prevention and control concerns. For example, communal bathrooms and toilets on the first floor had cracks in the sealed flooring which were visibly dirty in parts. This placed people at risk of the spread of infection as this type of damage and wear and tear can harbour microorganisms and make it difficult to clean and disinfect effectively. One relative we spoke to said, “The room needs a deep clean. While they clean every day, they don’t bother to lift things like cables and leads. They should move cupboards and furniture and clean behind things.” Another relative said, “The cleanliness of the room is not great. They do a basic every day clean, but don’t move stuff to get behind things and surfaces are often dusty. The room needs a top to bottom clean.”

The provider had an IPC audit from April 2025 which identified many of the issues seen on assessment which meant people were at risk of harm from identified risks that had not been resolved safely or effectively.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Most people we spoke with told us they felt their medicines were handled safely and staff were knowledgeable about their medicines. However, records held by the provider and completed by staff did not always support this. For example, fridge temperatures were not consistently recorded. When medicines are not stored at the correct temperature, they may become less effective or even unusable. Active ingredients in medicines can break down, meaning they might not work as intended. Repeated gaps were found in the recording charts. Reviews of records and medicines stored in people’s rooms showed dates of opening were not always accurately recorded. Some medicines have a certain shelf life once opened and without the date being accurately recorded this posed a risk of the medicine becoming ineffective. Stock take records reviewed by the assessment team did not consistently match the stock levels reviewed. This meant people were at risk of harm from not receiving their medicine in line with their prescribed dosage. Despite these concerns we did not find any evidence that anyone had suffered harm as a result. All appropriate staff had completed training in medicine administration.