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Phoenix Care Services Ltd Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 August 2019

About the service

Phoenix Care Services Ltd is situated in Lingfield, Surrey. It is the only service owned by the provider. It is a domiciliary care service providing support to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of the inspection, 24 people used the service, 23 of whom received the regulated activity of personal care. The service supported people with a range of needs, some were living with either a learning or a physical disability, others required support due to their older age and frailty.

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

People told us they felt safe, yet they were not always protected from the risk of harm. Medicines were not managed safely, and some people had gone without their prescribed medicines. Risks to people’s safety had not always been considered or lessened. Systems and processes did not always ensure that people were protected from the risk of abuse.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People’s privacy, dignity and confidentiality were not always maintained. Staff were not always responsive when there were changes in people’s needs. Staff had undertaking learning and development, yet findings found as part of the inspection raised concerns about their knowledge and understanding.

The service was not always well-led. Systems and processes did not enable the registered manager to have enough oversight to ensure people were receiving appropriate care. They had not notified us of incidents to enable us to have oversight and ensure that appropriate actions had been taken.

People told us staff were kind and compassionate. One person told us, “Carers are very nice. I get along with all of them.” People had access to healthcare and told us staff would contact the GP if they were unwell. People were happy with the service they received. One person told us, “Overall it’s very good, I’m impressed.”

Rating at last inspection

At the last inspection the service was rated as Good. (Published 22 December 2016). At this inspection, the overall rating for the service had changed to Requires Improvement.

Why we inspected

This was a planned inspection based on the previous rating. 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.


We have identified breaches in relation to people’s safety, their risk of abuse and improper treatment and the leadership and management of the service. The registered manager had failed to notify us of incidents that had occurred at the service. You can see what action we have asked the provider to take at the end of this full report. 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.


We will continue to monitor the intelligence we receive about this service. We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We plan to inspect in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 10 August 2019

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 10 August 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 10 August 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 10 August 2019

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 10 August 2019

The service was not always well-led.

Details are in our well-led findings below.