CQC report explained · a nursing home
What the CQC found at Pathfinders Specialist and Complex Care
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2020
Inspected but not rated; inspectors found good infection control practices during a targeted coronavirus review.
Inspectors visited the home on 5 November 2020. The visit was announced and focused only on infection prevention and control during the coronavirus pandemic.
They found that the home was following government guidance. Staff used suitable protective equipment, had received training, and testing was available for people living there and staff.
The home kept communal areas and bedrooms clean. People could stay in touch with relatives by telephone and video calls, and relatives could visit people at the end of their lives.
The home was inspected but not rated. This means the report does not provide an overall quality rating or ratings for most areas of care.
Keeping families informed
The home sent regular updates to relatives and helped people maintain contact through telephone and video calls.
“Regular newsletter bulletins were sent to relatives and family members to keep them up to date and informed about any changes to the service.” from the report
Protective equipment
Staff had training and updates about coronavirus and were observed putting on and taking off PPE safely.
“Staff were trained on to safely put on and take off their PPE and were observed wearing appropriate PPE.” from the report
Clean environment
Inspectors found the home clean, with enhanced cleaning and professional laundering of linen and towels.
“Systems for cleaning communal areas and people's bedrooms were effective. The service looked clean throughout.” from the report
Monitoring people's health
The home used observation tools and contacted GPs when concerns about people's health were identified.
“Where concerns were noticed, the provider liaised with GP to ensure appropriate treatment and medicines were prescribed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are your infection prevention and control arrangements different now from those inspected in November 2020?
- 02How do you make sure staff remain trained and competent in putting on and taking off PPE?
- 03How are relatives currently able to visit or keep in contact with people living here, including people at the end of their lives?
- 04How do you check that testing, cleaning and outbreak procedures are working in practice?
- 05What were the home's ratings for care, responsiveness, effectiveness and leadership at its last full inspection?
This was an announced targeted inspection of infection prevention and control only; the service was inspected but not rated. This explanation was written from the published report of 25 November 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2019
Rated Good overall, but inspectors found that safety required improvement because bed rails, medicine records and staffing arrangements were not always managed safely.
Inspectors visited the home on 28 and 31 October 2019. The first visit was unannounced. They spoke with people, relatives, staff and a visiting professional. They also observed care and checked care files, medicine records, recruitment files and management records.
The home provided personal and nursing care for people with complex health and social care needs. Inspectors found kind and respectful care, good rehabilitation support, suitable staff training and good involvement of people and relatives.
The main problems were about safety. Bed rails were not always managed safely, some people's identification photographs were out of date, and time-sensitive medicines were not always recorded at the time given. People and staff also reported delays with routine care when staffing was stretched.
The overall rating stayed Good, but Safe fell from Good to Requires Improvement. Effective, Caring, Responsive and Well-led remained Good. Inspectors said some problems were fixed quickly when they were raised, but the home's checks had not found them beforehand.
Kind and respectful care
People and relatives consistently described the staff as caring. Inspectors observed privacy, dignity and involvement in care.
“Every person and relative we spoke to, reported that the staff were caring.” from the report
Specialist support
The home had nurses and several therapy services on site. Staff received training for people's specific health needs.
“The service had nurses and a team of therapists on site.” from the report
Rehabilitation outcomes
Therapists set clear goals and records showed that some people improved enough to return home.
“Records showed that people had improved while using the service and some had improved enough to return to live at home.” from the report
Communication support
People with communication difficulties were assessed and supported with suitable aids. This helped them take part in decisions about their care.
“There was a strong ethos at the service of ensuring that people's views were heard.” from the report
Bed rail safety
seriousBed rails were not always supported by accurate records or safe guidance. Inspectors identified two people at risk of injury, although immediate action was taken when this was raised.
“Bed rails were not always managed safely at the service, this put people at risk of injury.” from the report
Medicine timing records
seriousThe time some medicines were given was not always recorded. The home corrected this by the second inspection day.
“Time sensitive medicines were not always recorded appropriately.” from the report
Out-of-date photographs
seriousSome photographs on care records no longer accurately represented the people concerned. This could increase the risk of staff reading the wrong person's record.
“We identified that some photographs were old and no longer represented the person.” from the report
Routine care delays
needs fixingPeople and staff reported that routine needs could be delayed when staff were dealing with more urgent needs. Inspectors observed one person waiting ten minutes for a drink, which caused anxiety.
“A person needed to wait for a staff member to get them a drink for ten minutes.” from the report
Checks missed problems
needs fixingThe home's quality checks had not identified the bed rail, photograph and medicine recording problems before inspectors found them.
“These had not been identified before inspection by the current auditing system.” from the report
- 01What changes have been made to assess and manage bed rails safely, and how are you checking that these changes remain effective?
- 02How do you make sure time-sensitive medicines are given and their exact times are recorded?
- 03How often are the photographs on care records updated, and what other checks prevent staff from using the wrong person's records?
- 04What has changed in staff deployment since inspectors reported delays with routine care?
- 05How does the current quality assurance system identify safety problems before they affect people?
This was a planned inspection covering all five CQC questions, the premises and the care provided; Safe deteriorated from the previous rating while the other four question ratings carried over as Good. This explanation was written from the published report of 3 December 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pathfinders Specialist and Complex Care
3 rated inspections over 4 years: the service has held its Good rating throughout.
- November 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Pathfinders Specialist and Complex Care →
- December 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Pathfinders Specialist and Complex Care →
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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