Choices Healthcare Limited

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• 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

The registered manager operated a robust quality monitoring system to help them identify areas for improvement within the service. Significant improvements had been made since our previous inspection of this service in February 2023 and that lessons had been learned and shared with the staff team.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were positive about the registered manager; they told us they felt listened to and had regular supervisions with a line manager.

During our last inspection in February 2022 we found there was a breach of Reg 17. The provider had made improvements and were no longer in breach of this regulation. The service sent us their action plan setting out their learning and improvement and how they had implemented audits and spot checks to help ensure they had clear oversight into the care people received. The previous inspection report identified areas for improvement which included accuracy and clarity regarding data for late and missed calls, quality monitoring of staff training and competencies and service audits were not robust and detailed enough. Following the report all audit processes were reviewed. Audit spreadsheets were completely redesigned to reflect analysis trends and patterns and intended actions. This enabled the registered manager to identify anyone whose care needs had changed. Since the last inspection, a new check and balancing system including medication error sheets, new medication audit sheets and action plans have been put in place. The registered manager told us, "All service our users now have a person-centred care/support plan which is tailor made to address and meet their individual needs and requirements. These records are regularly reviewed and updated."

The management team were open and transparent, and they collaborated with all relevant external stakeholders and agencies for the benefit of people using the service. For example, this included occupational therapists, GP surgeries and local authority assessment teams.

At the previous inspection (published February 2023) the provider’s systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users were not always effective. This was a breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this assessment we found the provider was no longer in breach of regulation 17. There was good evidence to show actions taken to improve the service since the previous inspection. For example, specific staff had been recruited to manage employment matters and to ensure staff were safely recruited and infection prevention and control policies and procedures had been reviewed and updated to reflect current guidelines.