We inspected the service on 23 November 2017. The inspection was unannounced. Pathways Health Care Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is a care home service with nursing. Pathways Health Care Limited is registered to accommodate ten people in one adapted building. On the day of our inspection eight people were using the service and the registered manager told us that two of the bedrooms were no longer in use and would not be in the future.

At the last inspection, in October 2015, the service was rated Good. At this inspection we found that the service remained Good. However, the rating for the Responsive domain has changed from Good to Requires Improvement.

The service had a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks in relation to people's daily life were assessed and planned for to protect them from harm and they lived in a clean, hygienic service. People were supported by staff who knew how to recognise abuse and how to respond to concerns. We have recommended the provider considers improving the system for analysing incident records to ensure this does not occur again.

Medicines were managed safely and people received their medicines as prescribed. People were supported by staff who sought to understand, prevent and manage behaviour that the service found challenging and supported by enough staff to ensure their personal care needs were responded to in a timely way.

People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. People were supported to maintain their nutrition and staff were monitoring and responding to people’s health conditions.

People lived in a service where staff listened to them and got to know them. People's support needs were recognised and responded to by a staff team who recognised the importance of respecting people’s privacy and dignity. Information about people's needs was shared between services to ensure people would be supported in other settings when needed.

People were supported to participate in activities and to socialise, however this was sometimes restricted due to the availability of staff. We have recommend the provider considers assessing staffing levels to ensure there are enough staff on duty to enable people to access the community when they wish to.

People lived in a service which met their needs in relation to the premises and adaptions were made where needed. People had access to information in a format which met their needs and were able to raise concerns if they needed to.

People were involved in giving their views on how the service was run and there were systems in place to monitor and improve the quality of the service provided.

During the inspection we spoke with two people who used the service and asked them about their experience of living at the home. We carried out a tour of the building and reviewed records relevant to the running of the service. We observed staff interaction with people throughout the home. We spoke with the registered manager, two support workers, a nurse, a domestic assistant and maintenance person.

During the inspection we focused on these five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People were supported and cared for in an environment that was safe, secure and met their needs. The communal areas were clean and tidy and the garden area was well looked after.

Care plans contained detailed information and guidance for staff that enabled them to provide care and support that met people’s needs and kept people safe. Records were well maintained and gave detailed information for staff on how to ensure that people were kept safe, whilst encouraging them to maintain as independent a lifestyle as possible.

We saw there were appropriate procedures in place for the safe handling, storage and administration of medicines. Records indicated people received their medication at the correct time by an appropriately trained member of staff. We observed the nurse administer medication to a person who used the service in a way that reflected their wishes within their care plan.

Appropriate checks had been made before staff commenced work at the home. References, criminality and qualification checks had been completed along with on-going registration with professional bodies such as the Nursing and Midwifery Council (NMC).

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted at the time of the inspection, proper policies and procedures were in place. The registered manager could explain the procedure for submitting an application, should one be required.

Is the service effective?

During our previous inspection on 14 August 2014, we identified concerns that had a minor impact on people who used the service. We found that where people did not have the capacity to consent to decisions about their care, the provider did not always follow the correct legal procedure for assessing and reassessing people’s capacity in accordance with the Mental Capacity Act 2005. During this inspection we found improvements had been made and where required, mental capacity assessments had been completed.

Staff spoken with had a good knowledge of people’s needs. They could explain the care and support each person who used the service required and how they ensured the support was effective. We observed staff interact with people and saw how their calm and patient approach, individualised to each person and their needs, produced a positive outcome for both the person who used the service and the staff member.

Care plan records showed people’s needs were regularly assessed. Where appropriate, external professionals had been consulted to offer guidance in areas that required expert input.

Is the service caring?

Staff approached and interacted with people in a calm and caring manner. They used supportive, non-judgemental language when assisting people with behaviour that challenges. We observed staff take calm action when a person became agitated when taking part in an activity of listening to their music. The techniques they used showed they cared about the person they were supporting and genuinely wanted to help them.

A person who used the service told us, “The staff seem to really care about me, it’s great.”

Is the service responsive?

We saw staff responded to people’s needs throughout the inspection. We saw the registered manager assist someone with making the right food choices for their lunch. They saw the person was in the process of making a portion of food that appeared excessive. The registered manager directed the person to some guidance, which was made available for people in the kitchen, on how to control portion sizes. The registered manager ensured, that as the person had capacity to make their own decision, they did not instruct the person to change their portion size, but responded to the issue by offering guidance in a calm and reassuring way. As a result of the registered manager’s guidance the person decided to reduce the size of the portion of their lunch.

We looked at records which confirmed that people’s interests, beliefs and needs had been recorded and identified and staff responded positively to these.

Is the service well-led?

The registered manager had effective processes in place to regularly monitor the quality of the service provided and whether people’s needs were being appropriately met. We saw regular audits took place to monitor the quality of care plans, the environment and the administering of medication.

People’s views were welcomed and acted on. Staff spoken with told us they felt able to raise any issues they had with the registered manager. They told us they felt supported and their views were respected. A care worker we spoke with told us, “The manager is brilliant, the manager has done our job before so she has experienced what we do. She knows how to relate to us.”

This inspection was carried out to follow up on our previous inspection in August 2013 where we found the provider had not been compliant with the outcome - "Consent to care".

Prior to our visit we reviewed all the information we had received from the provider, including an action plan detailing how they would comply with the compliance action we set at the previous inspection. During the visit we spoke with the manager and looked at some of the records held in the service.

We found the provider had made some improvements but had not completed all of the actions as stated in their action plan.

During this inspection there were eight people using the service. We spoke directly with two people who used the service and with three relatives. We also spoke with three care staff, a learning disability nurse, and the registered manager.

We saw evidence that people were consulted before receiving care. One of the people who used the service told us, "I can make my own decisions, but I get help with some."

We saw that where people did not have the capacity to consent, the provider did not act in accordance with legal requirements. Mental capacity assessments had not been conducted in line with the requirements of Mental Capacity Act (2005).

People were protected from the risks of inadequate nutrition and dehydration. A relative we spoke with told us, "My family member gets enough food and it is good quality."

There were enough qualified, skilled and experienced staff to meet people's needs. A person who used the service told us, "There's plenty of staff here to help me."

We saw that records relevant to the management of the service were well maintained and reflected the needs of people who used the service.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We looked at the records for two people who used the service, we spoke with two people and observed the support that one person required by one to one support from a care worker. We undertook a brief tour of the main home and looked at two bedrooms, laundry rooms and recreational facilities. We spoke with the manager, two trained nurses and a care worker.

People who used the service were being supported in accordance with their needs and preferences. One person told us, "I like the staff here, they help me and they are very good". We observed staff supporting people in a dignified way and communicating with them whilst providing support.

There were systems in place that ensured staff could recognise and respond to any concerns they had about the safety and wellbeing of people using the service.

The staff received regular training and they were supervised by the manager.

People told us they had seen their care plans. A person told us staff took their opinions into account. Another person told us they were not always listened to and their opinions were not always taken into account. A person told us they knew how to make a complaint and how to comment on the service but they had not received a survey asking for their views on the service. A person told us they had no privacy and were woken in their room.

People told us they were well cared for and felt safe. A person said, “I’m happy but people are bossy here.” Another person told us they were happy at the home.

A person said, “I’m sick and tired of having showers.” They told us they would like a bath in their en suite bathroom. They told us they would like to paint some of the rooms a different colour and they would improve the garden.

People told us that staff were helpful. A person said, “Some of them are well trained, some of them are not.”

People told us there were service user meetings. A person told us they had made complaints in the past and they had been responded to.

We carried out an unannounced inspection of the service on 29 and 30 October 2015. Pathways Health Care Limited is registered to accommodate up to ten people and specialises in providing care and support for people who live with a learning and/or physical disability. At the time of the inspection there were eight people using the service.

On the day of our inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were supported by staff who had attended safeguarding adults training, could identify the different types of abuse, and knew the procedure for reporting concerns. Risk assessments were in place to identify the risks to people’s safety and care plans were implemented to support staff in reducing these risks. Accidents and incidents were investigated thoroughly. Regular assessments of the environment people lived in and the equipment used to support them were carried out and people had personal emergency evacuation plans (PEEPs) in place.

People were supported by an appropriate number of staff. Appropriate checks of staff suitability to work at the service had been conducted prior to them commencing their role. People were supported by staff who understood the risks associated with medicines. People’s medicines were stored, handled and administered safely.

People were supported by staff who completed an induction prior to commencing their role and had the skills needed to support them effectively. Reviews of the quality of staff members’ work were conducted although these were not always completed often enough to ensure staff provided people with effective care.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The MCA is legislation used to protect people who might not be able to make informed decisions on their own about the care and support they received. The DoLS are part of the MCA. They aim to make sure that people are looked after in a way that does not restrict their freedom. The safeguards should ensure that a person is only deprived of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them. The registered manager was aware of the principles of DoLS and had made the appropriate applications to the authorising body for all people that required them.

The appropriate legal requirements had been followed when decisions were made for people who did not have the capacity to give their consent. People’s care records contained information which showed they had been consulted before decisions about their care had been made.

People were weighed regularly and where a risk to their health as a result of their weight had been identified support from external health care professionals was requested. People were supported to follow a healthy and balanced diet. People’s day to day health needs were met by the staff and external professionals. Referrals to relevant health services were made where needed.

People who used the service and their relatives felt the staff supported them or their family member in a kind and caring way. Staff understood people’s needs and listened to and acted upon their views. Staff responded quickly to people who had become distressed.

People were provided with the information they needed that enabled them to contribute to decisions about their support. People were provided with information about how they could access independent advocates to support them with decisions about their care, although the information was not easy accessible for people. Staff maintained people’s dignity. People’s friends and relatives were able to visit whenever they wanted to.

People’s care records were written in a person centred way. People and their relatives where appropriate, were involved with planning the care and support provided. People’s care records were regularly reviewed. People were encouraged to do the things that were important to them and they were supported to take part in activities individually and collectively with the people they lived with. People were provided with the information they needed if they wished to make a complaint, although the process for reporting concerns externally was not included on the complaints procedure.

The registered manager led the service well, understood their responsibilities and was liked and respected by people, staff and relatives. However we did find one example where they had not notified us of an incident, which should have been. Staff understood what was expected of them and how they could contribute to ensuring people received safe and effective care that met their individual needs. People were encouraged to provide feedback and this information was used to improve the service. There were a number of quality assurance processes in place that regularly assessed the quality and effectiveness of the support provided.