Best Pinnacle Care Limited

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• 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 – 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.

This is the first assessment for this service. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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.

The provider’s aims, objectives, and values were publicly available on their website. People were given a service agreement at the start of their support, which outlined key information about the service.

Staff told us about the organisation’s values, emphasising the commitment to ensuring people received the right support at the right time and in the most appropriate way. Staff told us the service fostered a positive culture that enabled them to deliver person‑centred care and achieve positive outcomes for individuals.

Leaders told us, “We pride ourselves on being a caring service-towards one another, towards our staff, and ultimately in the way this transfers into the care provided to the people who use our service.”

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.

People spoke positively about the leadership team, commenting how accessible they were and how promptly they responded to queries or concerns.

Staff expressed confidence in the leaders’ ability to manage the service effectively. One staff member commented, “They are supportive; we can easily call them to get the advice needed.”

Leaders had experience within the health and social care sector, enabling them to share their knowledge and support staff.

During the assessment, leaders acknowledged the shortfalls we identified and took immediate steps to address them. They told us they were committed to ensuring that risk assessments for people were completed and maintained, and governance practices would be strengthened, based on the feedback we provided.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they could raise concerns with leaders at any time and felt assured these would be taken seriously. They were aware of external agencies to which they could report concerns if needed.

Both staff and leaders described an open‑door approach within the service. In addition, an anonymous comment box was available in the reception area for staff who preferred not to raise matters directly.

A whistleblowing policy was available to support safe and confidential reporting.

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.

Staff told us they had no concerns regarding discrimination and reported that they had not personally experienced discriminatory behaviour within the organisation. A small number of staff described isolated incidents of racially discriminatory comments from people using the service. However, leaders responded promptly, communicated effectively with those involved, and provided appropriate support to staff to resolve the concerns.

The provider demonstrated awareness of their responsibilities under the Equality Act and their obligations to operate in accordance with this legislation. Staff said adjustments had been made for them when needed.

Policies and procedures were in place to support workforce equality, diversity, and inclusion. Staff had completed training in Equality, Diversity and Human Rights.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Audits were not always effective in identifying the shortfalls we found. For example, some risk assessments were not available for some medicines. Care plans had not been completed for people with specific diagnoses, and there was missing information relating to early warning signs for people with epilepsy. While the provider took steps to address these issues, this had not been fully embedded at the time of the inspection.

The provider lacked an effective system to monitor when staff logged in and out of visits. Leaders said they trusted and relied on staff adhering to schedules, and that people would contact the service if they had concerns about visit times. During the assessment, the provider introduced a system to track staff visit times.

Recruitment practices were not always fully aligned with the provider’s own policy or legislative requirements. This included unexplained gaps in applicants’ employment histories and instances where Disclosure and Barring Service (DBS) checks had not been received prior to staff commencing employment.

While a range of policies and procedures were in place to support governance, some required updating. There was a Business Continuity Plan (BCP), however, the information contained within it did not align with the organisation’s BCP policy. Key details, such as Local Authority contact information and IT provider contact details were missing. Not all critical analysis or recovery priorities were documented, and some sections did not have a risk analysis. This meant staff did not have access to clear, complete guidance on how to respond effectively during an emergency. The provider confirmed that no emergencies had occurred that required activation of the BCP, and therefore its effectiveness had not yet been tested.

The provider had not notified the Care Quality Commission (CQC) of a change of address, and some documentation continued to reference the previous address.

However, we observed evidence of regular audits that had identified and rectified some shortfalls. The provider had a service improvement plan which outlined areas of improvement needed.

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.

People told us that the service collaborated effectively with partner organisations on their behalf. Partner agencies also confirmed that the service worked with them to enhance and improve the quality of care to people. Leaders participated in meetings with local partners to strengthen shared learning and exchange relevant knowledge.

We saw evidence that people with learning disabilities were supported by staff to access and engage with their local communities. This included staff supporting with activities such as shopping trips and visits to relatives, helping to promote independence, social inclusion, and community participation.

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, effective practice and research.

The provider had a case management system which allowed them to effectively monitor and manage people’s care.

Leaders described their future strategic plans for the development of the service and acknowledged that these plans may be subject to change in response to social, economic, and financial considerations.

Following the feedback we provided as part of the assessment process, leaders outlined the actions they intended to implement. They took immediate steps to address the identified risk areas and submitted evidence to demonstrate the actions taken.