Pinnacle Caring Services Limited

On this page

• 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.At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 remained in breach of legal regulations in relation to governance at the service.

This service scored 61 (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. Staff were positive about the service and described the importance of providing a person-centred approach to people. Staff had access to and were expected to read the providers policies and procedures. Managers used supervision meetings to support staff to provide effective care.

Leaders did not always fully understand the context in which the service delivered care, treatment and support. Overall, they had the skills, knowledge, experience and credibility to lead effectively, and did so with openness and honesty. The registered manager was unavailable during our site visit due to unforeseen circumstances; however, we were able to have a telephone conversation with them.Staff told us managers were supportive. The provider monitored staff performance and was supporting staff including the registered manager to continue to develop their skills.The provider had not ensured they informed CQC of changes to their Nominated Individual (NI) The NI is responsible for supervising the management of the regulated activity. During the assessment they submitted the required notification to amend this.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they had regular contact with the registered manager, who visited people to undertake checks, as well as within individual and staff meetings. They told us they felt able to share feedback and raise any concerns. The provider had a whistleblowing policy, and the staff were aware of this.

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. The provider had an equality, diversity and human rights policy in place. Staff were positive about the way they were treated and supported at work. For example, the provider had supported a staff member to take time off to celebrate a religious festival.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. Since our previous inspection, the provider had taken some actions to improve governance systems, such as spot checks, supervision and audits. However, these had not identified the gaps we found in recording during our assessment. Records relating to medicines administration were not always in line with the provider’s policyand care plans/ risk assessments were not sufficiently robust. Therefore, the service remained in breach of the regulation related to governance.

The management team acknowledged they needed to embed effective auditing and strengthen other governance systems. The service supported 2 people, and the provider planned to strengthen systems prior expanding the service further. Last year, they had commissioned an external audit but had not yet embedded all the identified recommendations from this. They were responsive to our feedback and took immediate actions to address the recording issues in relation to medicines and met with staff to review other areas.

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. We saw they had worked with partners in health and social care to support a person’s changing needs in line with their wishes and preferences.

The provider had focused on continuous learning, innovation and improvement across the organisation and local system. They had made some improvements since our last inspection. However, the provider needed to ensure systems were fully embedded to ensure suitable learning and improvements were always identified and acted upon. The provider continued to look at options to improve aspects of the services such as the use of different electronic systems for planning and recording. They had arranged for an external mock inspection and said they planned to have another undertaken in the future.