Best Pinnacle Care Limited

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.

This is the first assessment for this service. This key question has been rated 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 service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed.

This service scored 59 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People told us the service was responsive when they called the office. Staff told us they discussed lesson learned during regular meetings and supervisions. We reviewed team meeting notes that showed conversations about concerns or incidents, along with clear guidance from leaders on how to prevent similar events in the future. A dedicated file was also available which clearly documented incidents, actions taken and outcomes.

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.

Most people had a hospital passport available within their records, however for 1 person with a learning disability we found a hospital passport was not available. This document outlines a person’s needs should they require hospital admission or emergency treatment. For example, reflecting the person had more complex needs arising from their distress and routines. Although the person had not recently attended hospital, there was a risk that the provider was not acting proactively and effectively to inform key staff and professionals in other services about crucial information to help them support the person appropriately in safe, person-centred ways. It also meant that the service was not meeting current best practice on the care of people with a learning disability under the Right support, Right care, Right culture statutory guidance. This statutory guidance is intended to ensure people with learning disabilities receive person-centred care and the opportunity to maximise independence, choice and control. Leaders acknowledged this omission and updated the documentation.

People told us the provider visited them to capture their initial needs when they started using the service. Staff also told us they received timely information about people through discussions, messages, care plans and risk assessments.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe with staff and had the contact details of leaders, should they need to raise issues. One person commented, “I feel safe in the company of the carers because they know what they are doing. They are gentle and caring and genuinely care.” Staff had completed safeguarding and Mental Capacity Act (MCA) training, which was refreshed annually. Staff we spoke with understood their duties to report any safeguarding concerns and how to do this.

A safeguarding log was available, clearly detailing each concern, the referrals made, and the outcomes. People and their relatives were kept informed throughout the process. Where safeguarding issues had been identified, care plans and risk assessments had been updated. Safeguarding discussions took place during team meetings and supervisions. A safeguarding policy was available, outlining the procedures and expectations of staff.

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.

We identified 1 person with a diabetes diagnosis did not have a specific diabetes care plan completed. This meant information to understand the person’s needs or the risks associated with their condition was not available to support staff.

We also saw a lack of information in care plans and risk assessments to guide staff on how to keep a person safe if they had an epileptic seizure.

The provider subsequently updated the care plans and provided evidence of this.

Although there were audits of care plans and risk assessments, these were not effective in identifying the shortfalls we found.

However, staff we spoke with showed an understanding of how to manage the risks and had completed training in diabetes and epilepsy. People told us staff supported them to manage their risks.

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.

The provider explained that during the initial assessment for live-in care, they checked whether a fire alarm was present in the person’s home. However, they did not confirm whether carbon monoxide monitors were installed, which placed staff staying in the home at risk of potential carbon monoxide exposure. There was no evidence of regular, ongoing checks of fire alarms, potentially putting staff at risk should a fire occur. Leaders stated they would introduce appropriate checks to manage these risks going forward.

We saw evidence that the provider had worked with external professionals to arrange fire safety checks for people in their homes. People told us they had the equipment they needed, and records showed the provider had liaised with other professionals to ensure appropriate equipment was in place. Care plans clearly identified where mobility aids were required and provided guidance for staff on how to support people safely.

Staff were not always safely recruited, and the provider had not always worked in line with their recruitment policies.

The provider’s policy stated applicants should, “Provide a full employment history without any gaps and make it clear in their application form if they are unable to recall some information.” It also stated, “any gaps must be discussed at interview and, if not clarified, a risk assessment must be completed.” We identified two staff members had unexplained gaps in their employment history which had not been explored, and no risk assessments had been completed to address these gaps. This meant the provider did not always ensure recruitment practices were in line with legislation and their own policy.

We reviewed one staff member’s Curriculum Vitae (CV) and found discrepancies between the employment dates listed on the CV and the dates recorded on their application form. This inconsistency had not been identified by the provider. In addition, the staff member had only provided the years of employment, not the months, which meant the provider was unable to accurately assess whether there were any gaps in employment. This meant there was a lack of recruitment checks in line with the provider’s policy and legislation.

The provider subsequently updated their application forms to include an additional section for applicants to explain any employment gaps, and we saw evidence it had been completed.

We also identified some Disclosure and Barring Service (DBS) had not been received before staff began working and no risk assessments had been completed. This meant checks had not been completed in line with legislation. Risks were slightly mitigated as the provider had obtained police clearance certificates from the staff members’ countries of origin to ensure they were suitable to work with vulnerable people.

However, the provider ensured there were enough suitably qualified, skilled, and experienced staff to meet people’s needs. People told us that staff were well trained, with one person commenting, “I feel well supported as the staff know what they are doing.” People said staff generally arrived on time for scheduled calls and stayed for the full duration.

Staff reported receiving regular supervision and support from leaders. We reviewed records showing meaningful supervision sessions, where topics such as people’s needs, safeguarding, and staff wellbeing were discussed. References had been obtained before staff started in their roles.

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.

People told us staff regularly wore personal and protective equipment (PPE). One comment included, “The carers are always changing their gloves, they dispose of them and clear up after themselves.”

Staff told us they had access to PPE and showed a good understanding of infection, prevention and control (IPC) practices. The provider had an IPC policy and procedure and staff had received training.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider did not always do everything reasonably practicable to mitigate the risks in relation to medicines.

For example, we identified 1 person did not have a risk assessment available for a high-risk anticoagulant medicine. Although no harm had come to the person this meant staff did not have clear guidance on how to manage the risk of bruising, prolonged bleeding, and anaemia associated with this medicine.

We identified that no risk assessments had been completed for people using paraffin-based emollient creams. The staff we spoke with demonstrated awareness of the fire risks and understood the actions required to reduce them. However, the fire risks associated with using these products had not been identified in documentation for staff to follow.

Following our feedback, the provider completed the necessary risk assessments and supplied evidence of this.

Additionally, 1 person’s medication administration chart (MAR) still listed a cream that had been discontinued more than a month earlier and had not been removed from the chart. We saw staff had continued to apply the cream on several dates after it had been stopped. We also found one person’s MAR did not include the dosage for one of their medicines. Although no harm had occurred, this meant there was a lack of accurate medicine recording and oversight. The provider took immediate steps to address this during the assessment.

Although audits of medicines were taking place, these were not effective in identifying the shortfalls we found.

However, people told us staff were competent when supporting them with their medicines. Staff received regular competency checks related to medicine administration. Care plans clearly outlined the level of support people required with their medicines and the types of medicines they needed assistance with. A medicines policy and covert medication protocols were in place, and arrangements for obtaining people’s medicines were documented within care plans.