Updated 2 April 2025
We carried out an unannounced assessment of Positive Care Solutions over 3 days starting on 5 November 2024. During our assessment we visited the head office for the organisation, then spent the 2 following days visiting the homes of service users. We gathered information from service users using the service, staff and managers, other stakeholders, and looked at a range of documents including care records, policies and procedures. Staff were caring and supportive, responded to patients needs and made sure they were involved in the planning and delivery of their care. There were sufficient staff, and they had received suitable inductions and training to enable them to carry out their roles. Risks were managed effectively; care plans were clear, and medicines were managed safely. Staff felt supported by their managers and felt they could raise concerns. However, we found one breach of regulation relating to governance. We found that governance processes were not always effective in monitoring and oversight of the service. This was because, team meeting minutes varied in their content and format. For example, the operations meeting minutes we were provided with lacked a clear agenda and actions/outcomes. In addition, although there were a number of audit processes in place, these had not always been effective in recognising shortfalls or errors. Audits concentrated more on checking if a task was completed than checking the quality of the work. Lastly, incident logs provided on the day of our assessment were basic and did not show evidence of review or learning from incidents.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care (Regulation 17(1))