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Phoenix Care Services Ltd Requires improvement


Inspection carried out on 11 June 2019

During a routine inspection

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 carried out on 15 September 2016

During a routine inspection

Phoenix Care Services is a domiciliary care agency that provides care and support to adults in their own homes. At the time of inspection, 32 people used the service. The service provided support for people in tasks such as cooking, shopping, general domestic tasks and personal care.

People who receive a service include those living physical frailty or memory loss due to the progression of age. The agency also provides services to people living with dementia and people with mental health needs.

The service had a registered manager, who was present on the day of the inspection visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People were protected from avoidable harm. We saw that staff received training in safeguarding adults and were able to demonstrate that they knew the procedures to follow should they have any concerns.

There were sufficient staff to keep people safe and to ensure that visits were completed within the agreed times. There was robust recruitment procedures in place to ensure that staff were safe to work with vulnerable people.

Staff had written guidance about risks to people health and safety and how to manage these. Risk assessments were in place for a variety of tasks like personal care, activities and the environment and were updated frequently.

People's human rights were protected as the registered manager ensured that the requirements of the Mental Capacity Act 2005 was followed. Staff assumed people had capacity to make decisions regarding their care, unless documentation was available to provide information that they do not.

People were happy with the support they received for example personal care and meal preparation. Changes in people's health care needs and their support was reviewed when required. If people required input from other healthcare professionals, this was arranged for them by staff.

People were supported by staff to maintain and improve their health and well-being. Staff supported people to have regular access to health and social care professionals.

Staff were trained and had sufficient skills and knowledge to support people effectively. There was a training programme in place and training to meet people's needs. Staff received regular supervision.

Positive and caring relationships had been established between people who received care, their families and the staff. We were told by people and their families that the staff interacted with people in a kind and caring manner.

People, their families, staff and other professionals were involved in planning people's care. We saw that people's choices and views were respected by staff. People's privacy and dignity was respected.

People received a personalised responsive service. Staff ensured that they supported people in ways that was their preferences and wishes and they were adhered to. People were supported by staff to maintain or to develop their daily living skills to promote their independence.

The care plans were person centred and contained clear, detailed information telling staff what support people wanted and how they wanted it.

The service was well led. The service listened to people, their families, staff and Social and Health professional’s views. The management welcomed feedback from people and acted upon this if necessary. The registered manager actively sought, encouraged and supported people's involvement in the improvement of the service by asking them to provide feedback formally by completing an annual quality check or informally during visits or telephone conversations. There were robust procedures in place to monitor, evaluate and improve the quality of care the service provided. The registered manager was passiona

Inspection carried out on 2 December 2013

During a routine inspection

We spoke with two people who used the service and one relative on the telephone. They were all satisfied with the care and support they received and were happy with the way they were treated. One person told us, "I look forward to seeing them so much (staff). They are like family to me". A relative said, "They're always here on time and don't seem rushed at all".

We saw that people's consent was obtained where possible before care and treatment was undertaken. We observed that the care given was safe and appropriate and based on effective care planning and risk assessments. This meant that people's individual needs were met and preferences were taken into account.

People were protected from abuse and cared for in a safe and inclusive environment. We also noted that people were cared for, or supported by, suitably qualified, skilled and experienced staff. In addition, the provider had an effective system to regularly assess and monitor the quality of service that people received.