This targeted inspection of Choices Healthcare Ltd Suffolk found that the provider had met the requirements of the Warning Notice relating to Regulation 17 (Good governance), reducing overall risk, but remained in continued breach of that regulation due to incomplete governance and oversight improvements. The overall rating of Requires Improvement is carried forward from the previous inspection as the well-led key question was inspected but not rated.
Concerns (6)
criticalGovernance: “Systems were not yet robust enough to demonstrate good governance. This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008.”
criticalCare planning: “At the time of our inspection not all care plans and risk assessments for people had been reviewed. This meant people were at risk because staff did not always have the guidance they needed.”
moderate
Record keeping
: “Auditing of staff files had begun, and gaps had been identified in some records. However, where actions were required, it was not always evident how this was effectively tracked and managed.”
moderateCommunication with families: “People and relatives shared that the handover process when the live in carers changed over was not always a smooth transition and communication was still mixed at times from the office.”
moderateConsent / capacity: “Work was ongoing to ensure the Mental Capacity Act was fully understood at all levels within the service and that records and practice supported shared decision making.”
minorIncident learning: “Reporting and auditing systems had been introduced but it was too soon to assess their overall effectiveness.”
Strengths
· Provider engaged with relevant partner agencies and was committed to developing the service, with the level of risk reduced and Warning Notice requirements met.
· Overall feedback from people and relatives was positive; no quality care concerns were reported.
· Improvements made to recruitment processes and a new manager appointed to support ongoing progress.
· Provider was proactive and responsive to people's concerns, with one person noting significant improvement in the last three months.
· Care plans and risk assessments were being updated, and Oliver McGowan Mandatory Training on Learning Disability and Autism was being considered for staff.
Quality-Statement breakdown (3)
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInsufficient evidence to rate
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInsufficient evidence to rate
well-led: Continuous learning and improving careInsufficient evidence to rate
Choices Healthcare Ltd Suffolk was rated Requires Improvement overall (with Safe rated Inadequate) following a December 2022 inspection that identified regulatory breaches across safeguarding, recruitment, safe care and treatment, and governance. The provider failed to notify CQC of safeguarding concerns, did not robustly assess DBS conviction information, and lacked effective governance systems to identify these risks, resulting in a Warning Notice for breach of Regulation 17.
Concerns (11)
criticalSafeguarding: “CQC were not informed of three safeguarding concerns. This is important for oversight of safety.”
criticalSafeguarding: “The provider did not have oversight of recruitment processes to ensure fit and proper persons were employed. This failure placed vulnerable people at risk.”
criticalGovernance: “Governance and monitoring systems were ineffective and failed to ensure people were safe, their rights were protected and they received quality care and support.”
moderateRecord keeping: “One person's care plan contained another person's name and other care records contained generic information not relevant to the person whose care plan it was.”
moderateCare planning: “People's care and support plans did not promote strategies to enhance independence and demonstrate evidence of planning and consideration of their longer-term aspirations.”
moderateMedication management: “We found unexplained gaps in the Medicine Administration Record (MAR) chart for one person which had not been identified or followed up to ensure medicines were received as prescribed.”
moderateMedication management: “Protocols for medicine to be administered 'as required' were not in place to guide staff.”
moderateConsent / capacity: “People were presumed to not have capacity and a blanket MCA form was used for assessment. An MCA policy and procedure to guide and inform on safe practice was not in place.”
moderateIncident learning: “There was not an effective system to monitor and analyse accidents and incidents for patterns and trends in place.”
moderatePerson-centred care: “Care and support was not always person-centred and did not promote people's dignity, privacy and human rights.”
minorCommunication with families: “Several people and relatives shared examples of poor communication and an unsettling and disruptive service during the changeover period.”
Strengths
· Most people and relatives spoke positively about their main live-in carer, describing being treated with kindness and respect.
· Staff received induction including training, assessed shadowing with experienced colleagues, and the Care Certificate programme.
· Staff and management worked collaboratively with other health and social care professionals, making timely referrals to specialist teams.
· People and relatives reported good infection control practice, with staff wearing appropriate PPE.
· Staff were positive about management support and described the team as approachable and accessible.
Quality-Statement breakdown (13)
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Staffing and recruitmentInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Learning lessons when things go wrongInadequate