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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 demonstrated a proactive and positive learning culture, underpinned by openness, honesty and a strong commitment to safety. Staff felt confident to raise concerns, which were listened to, appropriately investigated and consistently reported. Safety events were used as learning opportunities, with lessons identified and embedded to support continuous improvement. Since the previous assessment, the management team had strengthened oversight to ensure that identified errors were reviewed promptly and that ongoing risks were effectively mitigated. Learning from incidents, along with identified concerns and improvements, was shared openly with staff through regular communications such as memos and team meetings. This approach supported staff understanding of the potential impact on people when things went wrong and reinforced how incidents could be prevented from re‑occurring.

The provider worked closely with people and relevant healthcare partners to establish and maintain safe systems of care, where safety was effectively managed, monitored and reviewed. Systems were in place to ensure continuity of care, including when people transferred between services or experienced changes in their needs. Since the previous assessment, improvements had been made to ensure people had a personalised care plan developed within 48 hours of admission to the home, supporting the delivery of safe care that reflected their wishes and preferences. Multi‑disciplinary teams within the home worked collaboratively to ensure therapies, such as occupational therapy, were clearly identified and detailed within care plans where required. This supported consistency and safety in care delivery. Where additional input from external professionals was needed, this was identified promptly, and appropriate referrals were made to ensure people received timely and coordinated support.

The provider worked in partnership with people and relevant healthcare professionals to understand what being safe meant to each individual and the best ways to achieve this. Staff focused on improving people’s quality of life while supporting their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Since the previous assessment, the provider had strengthened safeguarding practices to ensure incidents and concerns were identified, documented and logged appropriately. These were consistently shared with relevant external partners, including the local authority and the CQC, in line with safeguarding expectations. This robust approach supported timely action, transparency and effective oversight to keep people safe.

The provider worked in partnership with people to understand and manage risks in a holistic and person‑centred way. Staff balanced safety with positive risk‑taking, providing care that was safe, supportive and enabled people to do the things that mattered most to them. Where appropriate, relatives were now actively involved in planning and reviewing people’s care. Relatives told us they felt included and well informed. One relative said, “Yes, 100% I’m included. Not only that, they, [staff] phone me with any changes or updates and don’t wait for a formal review.”

Care plans now contained clear and detailed guidance for staff on how to support people safely and how to recognise and respond to changes in people’s health or wellbeing, particularly where individuals were unable to communicate these verbally. This ensured risks were managed effectively while promoting people’s independence, dignity and wellbeing.

Since the previous assessment, the provider had made significant improvements to the home environment to ensure people’s safety. The management team had implemented a structured rolling audit and maintenance programme, which supported the early identification of urgent health and safety concerns alongside ongoing general maintenance of the home. This approach ensured the environment was well maintained, hazards were promptly addressed and risks were appropriately managed.

Issues identified during the last assessment had been effectively addressed. For example, potentially harmful cleaning chemicals were no longer accessible to people and were securely stored in small, locked safes within each unit of the home. This ensured substances remained safely controlled while still being readily accessible to staff when needed. These improvements demonstrated the provider’s commitment to maintaining a safe, well‑managed and person‑centred environment for people living at the service.

Since the previous assessment, the provider had made improvements to how staff were deployed across the home to ensure people received safe, effective and responsive care that met their individual needs. Staffing arrangements were reviewed to support continuity of care and enable staff to work together more effectively. This had a positive impact on people’s experience. One person told us, “Staff seem to be here in an instant now.”

Staff were assigned to specific units within the home, which supported the development of consistent and trusting relationships with people. This approach also improved staff understanding of people’s individual needs and preferences. Staff were further supported by an ongoing training programme, delivered by the provider’s training team, to ensure they had the skills and competencies required to meet people’s specialised healthcare needs, including tracheostomy care where required. These arrangements ensured staffing was safe, effective and responsive, supporting positive outcomes for people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. At this assessment, the provider had effective infection prevention and control systems in place to help reduce the risk of infection and protect people’s health and wellbeing. Cleaning checks had been implemented to ensure standards were consistently met and monitored across the service. Bedrooms reviewed during the assessment were clean, well maintained and presented to a high standard.

Staff completed daily cleaning records, which clearly identified equipment and areas requiring cleaning. This supported accountability and ensured cleaning schedules were followed consistently. These arrangements helped maintain a safe and hygienic environment and demonstrated the provider’s commitment to effective infection prevention and control practices.

The service had systems in place to safely store, administer and record the use of medicines.

We checked the quantities and stock balances of multiple medicines prescribed for five people and found them to be correct. This meant that we could be assured that the correct doses of medicines had been administered as signed for by staff. Thickeners added to fluids to ease swallowing problems were recorded when administered.

The service had implemented individual fire risk assessments for people who were prescribed paraffin-based skin products since our last inspection.

Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant we could not be assured that medicines requiring refrigeration were safe for use, however the provider had identified this within their audits and were supporting staff to make improvements.

The date of opening had been recorded on bottles containing medicines in liquid form. This meant that we could be assured that these medicines were not being used beyond the manufacturers recommended period after the date of opening. Instructions for medicines which should be given at specific times were available. Administering medicines as directed by the prescriber reduces the risk of the service user experiencing adverse effects from the medicine.

Some people were prescribed a medicine administered via a patch which needed rotating to different areas of the body, as recommended by the manufacturer. We found there was a process in place to indicate the site of the patch application. This prevented the patch being placed on the same site too frequently. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. Some people were prescribed a variable dose i.e. one or two tablets to be given when required at regular intervals. The time and quantity administered had been recorded, so that MARs accurately reflected the treatment people had received.

There were appropriate arrangements in place for the management of controlled drugs (medicines that require extra checks and special storage arrangements because of the potential for abuse). Records showed that staff completed regular balance checks in accordance with national guidance.

There was evidence that there was a process in place to record medicines related incidents or errors. Staff told us they had completed a training and induction process for medicines management.