Best Pinnacle Care Limited

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• 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of regulations.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People told us the service completed an assessment of needs when they started using the service. One person commented, “The transition home from the hospital went smoothly, and they even put in extra staff for a while because of the circumstances. Staff were also at the persons home to greet [Person] after another hospital discharge.”

Staff told us they regularly contacted leaders if they noticed people’s needs had changed, to ensure the appropriate action was taken. Staff also told us they received information in a timely way from leaders, when anything changed.

One professional told us, “The service have worked collaboratively with my client and other agencies to support safe transitions and continuity of care. The registered manager engages in planning discussions, shares relevant information appropriately and contributes to ensuring transitions are well-co-ordinated and centred on the individual’s needs.”

The provider now had hospital passports available which outlined people’s care and health needs and their communication needs, if they went into hospital. This was in line with Right support, right care, right culture guidelines to support people with safe pathways and transitions between services.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and their relatives told us risks were managed effectively by staff and the service.

The provider had now put in place care plans for people with diabetes and epilepsy, so staff knew what signs to be aware of and how to manage the risks. Staff told us care plans and risk assessments now contained enough information to manage risks for people. One staff member was clearly able to describe the way they needed to support someone who may have an epileptic episode. The provider now had audits of care plans and risk assessments which were effective in identifying any shortfalls in care documentation.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives told us they had access to the equipment they needed to ensure safe care was provided. Care plans contained details of the equipment people had available and how staff should support them with this.

The provider now completed regular fire safety checks where live-in care was being provided. This ensured that both the service user and staff were safe within the environment. Staff also confirmed these checks were now taking place regularly.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff had access to regular support, supervision and training. Staff confirmed this and we saw records to support this. Staff told us they had enough time to do their jobs and were not rushed between visits to people.

The provider had now amended their application forms to ensure gaps in employment were explored and recorded. We reviewed 2 new staff files and found the provider was now working in line with their policy and legislation. References had been sought prior to staff commencing work. Disclosure and Barring Service (DBS) had now been received prior to staff starting in their role.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People and their relatives told us they were supported safely with prompting and administration of medicines. Staff demonstrated good knowledge of how to support people and had completed appropriate training and competency assessments in medicines management.

Risk assessments were now in place for medicines requiring specific consideration. For example, risk assessments for paraffin‑based emollient creams included guidance on associated fire risks and how these should be mitigated. The provider had also implemented risk assessments for high‑risk anticoagulant medicines to support safe use.

We identified a minor documentation discrepancy where one person’s medicines administration record (MAR) indicated the medicine should be given in the morning; however, records showed it had consistently been administered in the evening. The registered manager explained this was a recording error, and the timings on the MAR chart reflected correct administration. There was no evidence of harm to the person, and the registered manager took immediate action to rectify the documentation.