Pathways Health Care Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. We raised areas of concern with the provider during the assessment in relation to the mixed feedback we received and staffing concerns that were raised about the use of agency staff. The registered manager was aware of the areas of concern and already had an action plan in place to address the areas raised. The registered manager evidenced regular meetings with staff to provide updates on improvement and recruitment. This demonstrated an open and transparent culture within the home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. One staff member said, “Things have improved since [registered manager] started, they adapt things as peoples need change, so roles change as needed as that’s good, it means everyone knows what they are responsible for.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a complaint policy in place, people, relatives and staff told us they knew how to raise a complaint. One staff member said, “Its been hard with the staffing challenges, the management team do listen to our concerns but sometimes it feels like nothing changes, but I would rather wait and make sure the right people are employed.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. One staff member described how the registered manager was flexible in accommodating requests for things like childcare issues or personal appointments. They said, “I cannot fault the support I have received with reasonable adjustments.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Governance systems identified areas for improvement. For example, incidents such as increases in falls or periods of distress and anxiety were regularly reviewed to identify any potential ongoing risks for people or within the environment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. External professionals we spoke with confirmed staff and the management team were knowledgeable and responsive to people's needs and wishes.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice. Staff were supported with an extensive training package and had an in-depth knowledge of people needs and wishes, they were able to keep people safe despite the ongoing recruitment and retention issues described in this report.