Pinnacle Caring Services 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.At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, 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. However, lessons were not always learnt to continually identify and embed good practice.Systems were in place to record and monitor incident or accidents, the provider advised there had been no recent incidents. Staff were proactive at following up on areas of concern. For example, staff liaised with health professionals to re-assess people and provide equipment. However, actions to embed good practice in response to audits had not been fully actioned and had not identified some areas for improvement that we found.

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. The provider told us they undertook assessments for any new people referred to them, to ensure they were able to meet their needs safely before providing a service. They liaised with partners to ensure people received appropriate support.

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.Staff had received training and told us they understood how to report any concerns related to safeguarding people. Whilst there had been no recent incidents, the provider understood what needed to be reported in relation to safeguarding, they had a policy in place and systems to ensure people were protected.

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. Whilst we found staff had taken actions to identify and mitigate potential risks when supporting people, records in relation to actions taken had not always been kept up to date. For example, in relation to guidance to staff about changes to a person’s moving and handling needs. Whilst familiar staff knew people well and how to support their needs, records were not always clear enough to provide up to date guidance on actions to manage identified risks. The provider told us staff undertook a risk assessment for each person, however for one person this was not available for staff to access at the person’s home. The provider said they would address this.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Staff undertook risk assessments which included any environment risks. Records included information where people had been supported by a fire service assessment and fire alarms fitted.

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. The service supported people by providing carers who lived-in with people. Each person was supported by a regular care worker who understood the person’s care and support needs. Where staff needed rest breaks or in emergency situations, staff from an agency supported people and the service aimed to use consistent and familiar agency staff. One person said, “Usually someone (agency staff) comes who has been before, they know me”.

The provider recruited staff safely. We reviewed paper recruitment records and raised a couple of queries around staff employment histories and dates. The provider clarified this and told us explanations had been recorded and stored on an electronic system.Staff were supported with relevant training and regular supervision meetings. Staff told us they saw the registered manager who undertook spot checks, and they felt supported.

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. Staff had received training in infection control and prevention. They told us they had access to PPE. Feedback from people indicated staff used PPE when providing personal care.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst the provider had a medication policyin place, they had not ensured staff robustly followed this policy or that effective record keeping was in place. Overall staff knew people’s needs well and administered their medicines as prescribed. However, records, relating to medicines taken “as required” and the application of topical creams needed to be clearer and more robust. Whilst people used homely remedies such as paracetamol for pain relief and we were advised staff consulted with their GP to ensure this was safe, the records were not clear about this. The provider used handwritten medication records (MARs) and the instructions for administering medicines needed to be more specific in some cases in relation to the appropriate time of administration. Following our feedback the provider took actions and developed new forms to ensure procedures were more robust in future.