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Pinnacle Brit

Overall: Inadequate read more about inspection ratings

01 Meadlake Place, Thorpe Lea Road, Egham, TW20 8HE (020) 8004 8866

Provided and run by:
Pinnacle Brit Care Ltd

Important: We are carrying out a review of quality at Pinnacle Brit. We will publish a report when our review is complete. Find out more about our inspection reports.

Latest inspection summary

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Background to this inspection

Updated 22 March 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

Our inspection was completed by two inspectors and an Expert by Experience undertook telephone interviews with people who used the service and relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

The service had a manager registered with the Care Quality Commission who was also the provider. This means they are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave the service 48 hours' notice of the inspection. This was because we needed the provider to inform people and seek their consent to be contacted and we wanted the provider to be in the office to support the inspection.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We called and spoke with two people who used the service about their experience of the care provided and spoke with eight relatives. At the office we spoke with six members of staff including the provider (who was also the registered manager), field care supervisor and care staff.

We reviewed a range of records including five people’s care plans, daily care notes, staff rotas, multiple medication records, safeguarding records and complaints. We reviewed a variety of records relating to the management of the service including three staff recruitment files and audits of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and policies.

Overall inspection


Updated 22 March 2022

About the service

Pinnacle Brit provides personal care and support to older people and people with disabilities living in their own homes. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. At the time of our inspection all 40 people supported by the service received personal care.

People’s experience of using this service and what we found

People's medicines were not being managed in a safe way which put people at risk. Staff were not trained or assessed as safe to administer medicines to people. Accidents and incidents were not always reported, and actions were not always taken to reduce reoccurrence of them.

Good infection control was not always being followed and assessments of the risks associated with people were not always assessed. The provider had not ensured that there was sufficient organisation of the staff rotas and we found that staff were at times late for calls and did not always stay for the duration of the call.

The provider and staff were not following procedures that related to safeguarding people from the risk of abuse or neglect. The recruitment of staff was not robust which put people at risk. Staff were not sufficiently trained or supervised to ensure that they were competent to carry out their role. There was a lack of understanding of the Mental Capacity Act and its principles. Where people's capacity to make specific decisions was in doubt there was no assessments undertaken by the provider.

Prior to people receiving care there was a lack of assessment of their needs. People's care was not provided in a consistent way. Care plans lacked detail and guidance for staff and information about people's backgrounds, interests and things that were important to them. Where people were being cared for at the end of their lives there was no care planning in place around this.

Where people and relatives complained about their care, this was not recorded, and insufficient actions were taking place to address their complaints. There were no systems in place to assess the quality of the care being provided. Notifications that are required to be sent to the CQC were not always being done.

There were people and relatives that told us that they felt safe with staff and there were some relatives that felt staff developed good relationships with their loved ones. Staff fed back they felt supported by the leadership.

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 24 December 2020) and there were three breaches of regulation. We only looked at the Safe, Responsive and Well-Led domains at this inspection as we had concerns around these areas. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we looked at all of the domains and we found improvements had not been made and the provider remained in breach of regulations and further regulations had been breached.

Why we inspected

The inspection was prompted in part due to concerns received about the care and support people received and the way the service was managed. We decided to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive, and Well-Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pinnacle Brit on our website at www.cqc.org.uk.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risks related to lack of robust systems in place to ensure staff arrived at the call and stayed for the duration, safe care being provided to people, and lack of detailed care planning. Breaches were also in relation to staff training and supervision of staff, a lack of understanding of the Mental Capacity Act (MCA) and the lack of robust provider and management quality assurance at this inspection

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect in six months and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.