The Care Quality Commission
  • Mental Health
  • Independent mental health service

Head Office

Overall: Good read more about inspection ratings

Lowry Mill, Lees Street, Manchester, Lancashire, M27 6DB (0161) 592 4491

Provided and run by:
Positive Care Solutions Ltd

All Inspections

During an assessment of Specialist community mental health services for children and young people

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.

During an assessment of the hospital overall

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))

5 - 6 July 2022

During a routine inspection

This was the first time we had inspected and rated this service. We rated it as requires improvement overall because improvements were required in relation to the safe and well led key questions. However, we did find that the service was effective, caring and responsive.

We rated the service as requires improvement because:

  • The provider did not have a restraint reduction programme in place which is a national requirement for all services using physical interventions in response to disturbed behaviour by people with a learning disability and/or autism.
  • The provider’s systems for training staff and monitoring compliance in relation to mental health legislation such as the Mental Capacity Act and the Mental Health Act were not fully embedded.
  • Records did not always show how all agencies involved with an individual’s care had been involved in their care planning where this would have been appropriate.
  • Notifiable incidents had not always been shared with CQC in accordance with regulatory requirements.
  • The provider’s governance systems had not highlighted the issues we identified in relation to the care records and the lack of adequate safeguards in relation to the use of physical interventions.

However:

  • Staffing levels on each shift enabled staff to give each young person the time they needed as teams were not short-staffed.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment of young people’s needs and in collaboration with young people using the service and, where appropriate, their families and carers.
  • The provider evaluated the quality of care they provided and made improvements on an ongoing basis.
  • The teams included or had access to the full range of specialists required to meet the needs of the young people using the service. Managers ensured that these staff received adequate supervision and appraisal.
  • Staff treated young people using the service with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved young people using the service and, where appropriate, their families and carers in care decisions.
  • The service was easy to access. The criteria for referral to the service did not exclude young people who would have benefitted from care and the service had no waiting list at the time of our inspection.