Archived: Phoenix House

Phoenix House provides accommodation and personal care for up to 24 people who need support with their mental health needs in one adapted building. There were 16 people living at the service at the time of the inspection. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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

People had been harmed or were at risk of harm due to poor risk management. Safeguarding incidents were not always reported or investigated appropriately. Lessons were not learnt, and people continued to be at risk of harm from other people. People continued to receive medicines to control their behaviour in an inconsistent way, people’s health needs were not managed safely. There were not enough skilled or trained staff to support people.

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. Staff were poorly trained and supervised. Due to their lack of knowledge or skills, management of incidents was poor and people had been unnecessarily restricted as a result. People were not empowered to take control over the lives, they were not supported to develop skills and reach their full potential. Working with other healthcare professionals did not always happen leaving people at risk from health needs such as diabetes or constipation.

The provider had failed to act to rectify shortfalls found at previous inspections. This is the seventh consecutive inspection where the service has been rated either requires improvement or inadequate. There has been no sustained improvement. The provider and their representatives have continually failed to provide sufficient oversight of the service and has not responded appropriately to the concerns we have raised.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Inadequate and was placed in special measures (published 20 December 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service has been inspected seven times since November 2015 and has continued to be rated either Requires Improvement or Inadequate. At this inspection not enough improvement had been made or sustained and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 7 & 8 October 2019. Breaches of legal requirements were found in safeguarding service users from abuse and improper treatment, safe care and treatment, staffing, dignity and respect, person-centred care, good governance and notification of other incidents. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has stayed the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Phoenix House on our website at www.cqc.org.uk.

We have found evidence that the provider needs to make improvement. Please see the Safe, Effective and Well-led sections of this full report.

Enforcement

We have identified breaches in relation to Safe care and treatment, Safeguarding service users from abuse and improper treatment, Staffing, Person-centred care, Dignity and respect, Need for consent, Good governance and Notification of other incidents at this inspection. We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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.

Follow up

The overall rating for this service is 'Inadequate' and the service remains in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Phoenix House provides accommodation and personal care for up to 24 people who need support with their mental health needs in one adapted building. There were 18 people living at the service at the time of the inspection. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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

The provider had failed to act to rectify shortfalls found at previous inspections. Lessons had not been learned and people continued to be at risk and were unable to live their lives in the way they wanted. People were not protected from the risk of harm. We found one person had numerous unexplained bruises which had not been investigated. Risks were identified but measures to reduce risk were not effectively re-assessed or implemented leaving people at risk of potential harm. One person had been given medicine to control their behaviour on numerous occasions without a valid reason. Some people were at risk of choking, but guidance had not been followed to reduce this risk. Peoples health needs were not always managed safely.

All people living at the service had been unnecessarily restricted up until the new manager had taken up post in August 2019. For example, the kitchen, toilets and bathrooms had been locked to prevent people from accessing them alone. 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. Health needs were not always supported well. Some people were diabetic but information to instruct staff in how to support them was lacking or missing. Processes to support people to eat safely and drink enough were not robust.

Whilst we observed some positive interaction between people and staff there remained a divide in the culture which did not demonstrate inclusion. People had not been supported to develop skills, set goals or achieve aspirations. Activities lacked personal meaning and people had not been encouraged to become more independent. People were not involved in their care planning and had not been given information in an accessible way.

There was poor accountability and oversight by the provider. The provider had failed to provide an inclusive, open or empowering environment for people and had not challenged the restrictive practice that people had been subjected to. The provider has failed to demonstrate how they have learned from previous inspections so the people receiving services were provided with safe care and support. People had not been fully involved or informed about the service.

Staff records showed that new staff were recruited safely. Staffing levels were enough to meet people's immediate needs. Staff had received training to support people although further improvement was required in this area. The complaints procedure was in an accessible format and included up to date, relevant information of how people or other individuals could complain.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 19 October 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service has been inspected five times since November 2015 and has continued to be rated either Requires Improvement or Inadequate. At this inspection not enough improvement had been made or sustained.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to Person-centre care, Dignity and respect, Safe care and treatment, Safeguarding service users from abuse and improper treatment, Good governance and Notification of other incidents at this inspection.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Phoenix House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under on contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Phoenix House provides accommodation and personal care for up to 24 people who need support with their mental health needs in one adapted building. There were 15 people living at the service at the time of the inspection.

The service had a registered manager. A registered manager is a person who has registered with the CQC 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.

The service was placed in special measures following our inspection in July 2017, when the service was rated inadequate in all domains. We took enforcement action and placed a restriction on the provider’s registration so they could not admit any people to the service without prior written consent from CQC. We inspected the service on 06 March 2018 to check that the provider had complied with their action plan and confirm that they now met legal requirements. Improvements had been made but there were continued breaches and a new breach of regulations.

We found breaches of Regulations 9, 10, 12, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Risks to people had not been identified, assessed and mitigated. The provider had failed to ensure that care was provided in a safe way to people. The provider had failed to ensure that staff were safe to work with people. The provider failed to ensure that staff were suitably qualified, competent, skilled and experienced. People's independence and autonomy was not fully promoted. The provider had failed to consistently involve people and their relatives in planning their care and people did not always receive person-centred care. The service had not sufficiently improved or developed. The provider had failed to maintain accurate and complete records. The provider had failed to establish and operate systems to assess, monitor and improve the quality of the services provided and reduce risks to people. The registered manager had not been working full time at the service for some months, and the service had not sustained improvement and was rated Requires Improvement overall and Inadequate in well led.

The provider sent us regular updates and action plans with timescales stating they would be compliant with the regulations. We undertook this inspection to check they had followed their plan and to check that they now met legal requirements. Improvements had been made and the service now met legal requirements but some further improvements were needed for the service to be rated Good overall. This is therefore the fifth time the service has been rated Requires Improvement or Inadequate.

Previously, the registered persons had failed to monitor, support and have oversight of the service. The registered manager was now working full time at the service and the provider completed a monthly audit of the quality of the service. The registered manager had completed checks and audits, shortfalls had been identified and action had been taken. However, there was no action plans in place to identify what needed to be done, who was responsible and when it should be completed by. This was an area for improvement.

There had been a towel rail that was very hot and there was a risk of scalding, at this inspection, it had been covered. Regular audits had been completed on the building and any shortfalls had been rectified.

At this inspection, improvements had been made relating to the management of risk, there was now detailed guidance for staff to follow including about health conditions such as diabetes and blood thinning medicines. However, there was not a plan in place with guidance about how staff support one person to self-administer their medicines safely. Staff could describe how they supported the person to keep them safe. On the second day of the inspection, a plan was in place.

There were now details about what people could do and what they wanted support with. People were involved in reviewing their plans with staff and professionals and had signed the plan to confirm this when they were able. The plans contained information about how people should be supported to be more independent. The plans did now contain goals for people to achieve, but these were vague and did not have information about how staff would know if the person had reached their goal. This was an area for improvement.

At this inspection, when one person came back to the service from hospital, the registered and deputy manager had assessed the person’s needs.

The registered manager had rectified the concerns about staff references, from the last inspection. Recent staff recruitment had been completed in line with legal requirements. Staff now received training appropriate to their role, including online and face to face. Staff attended additional training from the Health Authority and Care Home Nurse Specialists. Staff received regular supervision and appraisals, these were used to discuss and review staff performance. There were sufficient staff to meet people’s needs.

At this inspection, life style was discussed at resident meetings, meals were now low fat and portions had been reduced, people had lost weight and their health had improved. People were supported to eat and drink a balanced diet. People had not always been empowered to be as independent as possible, staff now supported people to clean their rooms, simple cooking and do their own laundry. Staff were reminded in staff meetings and supervision, that this was an essential part of the support given to people.

People’s physical and mental health was monitored by staff, any changes were reported to health professionals. Staff supported people to attend appointments and followed the guidance from professionals. Incidents had been recorded, analysed and patterns identified. The registered manager had acted and the incidents had reduced, this included referrals to health professionals. However, the action taken was not always recorded in detail, this was an area for improvement.

People’s dignity and privacy was respected and treated with compassion. People and staff had developed friendships, people were supported to take part in activities they enjoyed such as fishing or swimming. However, there was still no formal activities plan for each individual, this continued to be an area for improvement.

People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible; the policies and systems in place supported this practice.

People were protected from harm and abuse. Staff knew how to recognise signs of abuse and how to report these concerns. Staff were confident that the registered manager would deal with the concerns appropriately. The registered manager had reported any concerns to the local safeguarding team and followed the advice given to reduce the risk of them happening again.

People received their medicines safely and when they needed them. The service was clean and there were procedures in place to protect people from infection. The service had been adapted to meet people’s needs and there were plans for further improvements.

People and staff attended meetings where they discussed the service and made any suggestions. The registered manager understood the requirement to discuss with people their end of life wishes, where people had been happy to do so this was recorded.

There was an open and transparent culture within the service, people knew the registered manager and were happy to talk with them when they were anxious. People told us they knew how to complain; the complaints policy was displayed in the service. This and other information was not available in easy read format, this was being developed by the registered manager and was an area for improvement.

Professionals had been asked their opinions on the service and the feedback had been positive. The registered manager had developed good working relationships with outside agencies. The registered manager attended local forums and registered manager meetings to keep up to date and continuously improve the service.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. CQC check that appropriate action had been taken. The provider had submitted notifications to CQC in an appropriate and timely manner in line with guidance.

It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service where a rating has been given. That is so that people, visitors and those seeking information about the service can be informed of our judgements. We found the provider had conspicuously displayed their rating on a notice board in the entrance hall and on the website.

Phoenix House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Phoenix House provides accommodation and personal care for up to 24 people who need support with their mental health needs. There were 14 people living at the service at the time of the inspection. The service is situated in its own extensive grounds and gardens in the rural village of Northbourne, which is close to the seafront towns of Deal and Sandwich.

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 40s and the oldest was in their 70s.

As well as needing support with their mental health conditions, some people required more care and support related to their physical conditions. Some people were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out on their own.

The service had a registered manager. They started work at the service in July 2017 and registered with the Care Quality Commission (CQC) in December 2017. A registered manager is a person who has registered with the CQC 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. The registered manager had not been working at the service full time for some months and was on a phased return working three days a week.

The last inspection was carried out on 7 July 2017. Concerns had been raised by whistle blowers and staff in the local safeguarding team. We found continued breaches of the regulations from our inspection on 13 December 2016. We also found new breaches of the regulations at the July 2017 inspection. The service was rated Inadequate in all domains and was placed in special measures. We took enforcement action and placed a restriction on the provider’s registration so that they could not admit any people to the service without prior written consent from the CQC.

The provider sent us regular action plans and updates with timescales stating when they would be compliant with the regulations. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. Some improvements had been made, however we found some continued and a new breach of the regulations. This is therefore the fourth consecutive time the service has been rated Requires Improvement or Inadequate showing un sustained improvement.

At this inspection the provider had failed to comply with their action plan with persistent shortfalls including the way risk was managed, people’s involvement and engagement, governance, environmental risks, recruitment checks, training and induction of staff.

The registered persons continued not to have oversight and scrutiny to monitor and support the service. There was a lack of continuity in the leadership and management of the service, which had impacted on people, staff and the quality of the care provided. There were quality assurance systems in place, which included reviewing and updating care plans, audits, health and safety checks, but these had not identified the shortfalls found at this inspection. Some records could not be located, were not suitably detailed or accurately maintained. Previous breaches of regulations had not been addressed and the breaches continued. Poor record keeping was identified as a breach of the regulations at the last inspection and continued.

Risks relating to people's care and support had not always been assessed and mitigated. Improvements had been made in reducing the risks when people exhibited behaviours that could be challenging but these needed further information to make sure people were consistently supported and safe. Not all environmental risks had been identified. There was a towel rail in shower room that was very hot and posed a risk of scalding. A fire door was propped open by a chair preventing it from closing automatically in a fire. Ineffective risk management was an issue at the last inspection and the breach of regulation continued.

Some care plans had improved but not all care plans contained the information needed to make sure people received the care and support that they needed. Goals and aspirations had not been identified and people were not fully involved in deciding what care and support they wanted. This was identified as breach of the regulations at the last inspection and continued to be a breach at this inspection.

There had been no new people admitted to the service since the last inspection. However, one person had returned to the service from hospital. The staff could not find any information to show that they had re-assessed the person’s needs to make sure staff were able to meet their needs. The assessment for another person lacked detail and did not show how potential risks would be managed.

Staff were not recruited as safely as they should be. Staff had not received the training, support and supervision necessary to complete their roles effectively. There were sufficient numbers of staff. The provider had recently employed new staff and when there were shortfalls agency staff were used.

People’s physical and mental health was monitored. Staff supported people to make and attend medical appointments. However, supporting people to live a healthy life style was not promoted for all people. There was a lack of support for people who smoked to give up smoking and people were not encouraged to exercise and improve their health. People’s end of life wishes had not been considered or discussed with them.

People were not always empowered to have as much control and independence as possible with aspects of their lives. Staff continued to do some activities for people rather than with them. Activities were ad hoc and up to the staff on duty to arrange rather than planned for everyone individually. This was identified as breach of the regulations at the last inspection and continued at this inspection. People’s privacy and dignity was now respected. Staff were caring and good relationships had developed between staff and people.

People were protected from harm and abuse. When incidents had occurred the staff followed safeguarding protocols and incidences were now reported to appropriate agencies. Referrals had been made to the local safeguarding authority when safeguarding incidents had happened. The staff had informed CQC of important events that occurred at the service, in line with current legislation. Accidents and incidents had been recorded but not all had been fully investigated and analysed to ensure action was being taken and to reduce the risks of further events.

People received their medicines safely and when they needed them. Further guidance was needed for when people needed medicines now and again like pain relief to make sure they received their medicines consistently. Medicines were stored safely although each person previously had their own medicine cupboard in their rooms. This had been changed and medicines were now stored centrally in a trolley removing some control from people. People were offered and received a balanced and healthy diet. When people were at risk of losing weight this was monitored and they received a high calorie diet.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There was now more understanding about staff responsibilities under the Mental Capacity Act 2005 and DoLS. Mental capacity assessments had been completed by the staff to decide whether or not people were able to make decisions themselves. DoLS had been applied for people who needed them.

People told us they knew how to complain and were confident that their complaints would be taken seriously and the necessary action taken to address their concerns. The registered manager had followed policies and procedures to deal with complaints effectively. People and staff had the opportunity to attend regular meetings to give their views and suggest improvements.

The service was clean and there were procedures in place to protect people from infection. Some parts of the service had been decorated and there were plans for further improvements.

There had been improvements with developing relationships with other agencies like social services and the community mental health team. The staff were working more closely with them.

We found new and continued breaches of the Health and Social Care Act 2008 (Regulated

Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is Requires Improvement but remains 'Inadequate' in Well led and the service therefore remains in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their regi

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 40's and the oldest was in their 70's.

As well as needing support with their mental health, some people required more care and support related to their physical conditions. Some people were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out on their own.

The last inspection was carried out on 13 December 2016 when we found continued breaches of the regulations from our inspection on 3 November 2015. The service was rated 'Requires Improvement' and 'Inadequate' in the 'well-led' domain. The provider sent an action plan to CQC in February 2017 with timescales stating they would be compliant with the regulations by March 2017. At this inspection the provider had failed to comply with their action plan and there were continued breaches of the regulations relating to safe care and treatment, treating people with dignity respect that promoted their independence and autonomy, person centred care and good governance. There were also new breaches identified relating to need for consent, safeguarding people from abuse and proper treatment, staffing, not notifying the relevant bodies when incidents occurred at the service and complaints.

The service did not have a registered manager in post. 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.

The registered manager had left in March 2017. We contacted to the registered provider about this before the inspection. A new manager had been appointed in April 2017 but they left in June 2017. Another manager had been employed and they were due to start work at the service on 10 July 2017. In the meantime the provider’s business manager was supporting the service but was not at the service every day. The deputy manager of the provider’s other service was supporting the service. When we returned for the second day of our inspection we met the new manager.

The provider had not taken appropriate steps to ensure they had oversight and scrutiny to monitor and support the service. There was a lack of continuity in the leadership and management of the service, which had impacted on people, staff and the quality of the care provided. There were quality assurance systems in place, which included reviewing and updating care plans, audits, health and safety checks, but these had not been consistently undertaken. Records were not suitably detailed or accurately maintained. Previous breaches of regulations had not been addressed and the breaches continued.

Some people told us they did not feel safe at the service. People were not fully protected from harm and abuse. Incidents had occurred when people and staff had been hurt. The staff had not followed safeguarding protocols and incidences had not been reported to out-side agencies. Referrals had not been made to the local safeguarding authority when safeguarding incidents had happened. The staff had not informed CQC of important events that occurred at the service, in line with current legislation.

Potential risks to people were identified, like diabetes, choking and when people had behaviours that could be challenging. Full guidance on how to safely manage the associated risks was not always available. There had been occasions when people displayed behaviours that may challenge. There were no step by step guidelines in place to explain to staff how to support people in a way that suited them best. Staff had given inconsistent support which left people at risk of not receiving the support they needed to keep them as safe as possible. Some accidents and incidents had been recorded but some had not. There was no analysis or oversight of the accidents and incidents. Triggers, patterns and interventions had not been identified to try and reduce the risk of re-occurrence.

Generic emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. However, personal emergency evacuation plans (PEEPs) were still not adequate and did not contain information about people's individual needs during an emergency evacuation. This was identified as breach of the regulations at the last inspection and continued to be a breach at this inspection.

People were not fully supported effectively with their health care needs. There had been delays in accessing health care specialists when they were needed. People’s medicines were not always managed safely. People did received their medicines when they needed them. When people needed ‘as and when’ medicines there was not always guidance in place and hand written entries on medicine records had not been countersigned. When errors had occurred they were not investigated to prevent re-occurrence.

Care plans did not contain all the information needed to make sure people received the care and support that they needed. The process of reviewing and updating people's care plans had fallen behind due to the lack of leadership and management. Some care plans had been reviewed but people had not been fully involved in reviewing their care plans to have a say about how they wanted to receive their care and support. This was identified as breach of the regulations at the last inspection and continues to be a breach at this inspection.

People were not always empowered to have as much control and independence as possible with aspects of their lives. People were not always treated with dignity and respect that promoted their independence and autonomy. This was identified as breach of the regulations at the last inspection and continues to be a breach at this inspection.

People told us they knew how to complain. However, we were not confident that their complaints would be taken seriously and the necessary action taken.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There was lack of understanding about staffs responsibilities under the Mental Capacity Act 2005 and DoLS. Mental capacity assessments had not been completed by the staff to decide whether or not people were able to make decisions themselves. At the time of the inspection DoLS had not been applied for people who needed them. When people did not have the capacity to make complex decisions, which were usually for medical procedures, there was no evidence that best interest meetings had been held.

There was a task orientated culture at the service, staff were busy doing different chores rather than spending time with people. Staff did not have the time to spend with people to give them person-centred care. People told us that they were bored and had nothing to do. They said they were not going out as much as they used to and missed going places and doing different activities. Staff said that more activities were needed for people. Some people were able to go out daily and do what they wanted to in the local area.

People had their needs met by sufficient numbers of staff. The provider had recently employed new staff and when there were shortfalls agency staff were employed. However, we were told there had been times when there had not been enough staff. People and staff told us that sometimes planned activities were cancelled as there was not enough staff available. Staff had not received the training and supervision necessary to complete their roles effectively.

Most staff knew people and their preferences and life histories. Staff were recruited safely. Contact with people's family and friends, who were important to them, was well supported by staff.

No new people had moved to the service since the last inspection but there were procedures in place to assess people prior to them coming to live at Phoenix House.

People were offered and received a balanced and healthy diet.

We found a number of new and continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. The youngest person was in their 40’s and the oldest was in their 70’s years.

As well as needing support with their mental health, some people required more care and support related to their physical conditions. Most people were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out on their own.

The previous inspection of this service was carried out on 3 November 2015 when we found breaches of some regulations. The provider sent an action plan to CQC in December 2015 with timescales stating they would be compliant with the regulations by December 2015. At this inspection the provider had failed to comply with their action plan and there were continued breaches of the regulations relating to safe care and treatment, the recruitment of staff, treating people with dignity and respect that promoted their independence and autonomy and good governance.

There was a registered manager working at the service. 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. A deputy manager had recently been appointed to support the registered manager.

At the previous inspection staff were not always recruited safely, at this inspection there still shortfalls. The provider had policies and procedures in place for when new staff were recruited, but these were not consistently followed. All the relevant safety checks had not been completed before staff started work.

Some care plans did not contain all the information needed to make sure people received the care and support that they needed. The process of reviewing and updating people’s care plans had fallen behind due to staff shortages and the registered manager had spent a lot of their time working with the care staff team to make sure people’s daily needs were met. A staff member had now been employed to make sure people’s care plans were reviewed and updated, however the care plans were written in negative way and indicated that staff controlled the way people behaved. People were not always empowered to have as much control and independence as possible with aspects of their lives. People had not been fully involved in reviewing their care plans and how they wanted to receive their care and support. People were not always treated with dignity and respect that promoted their independence and autonomy

Potential risks to people were identified, like diabetes, eating safely and when people had behaviours that could be challenging. Full guidance on how to safely manage the associated risks was not always available. This left people at risk of not receiving the support they needed to keep them as safe as possible. Accidents and incidents had been recorded and action had been taken to reduce any risks to people.

Generic emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. However, personal emergency evacuation plans (PEEPs) were not adequate and did not contain information about people’s individual needs during an emergency evacuation. This was identified as breach of the regulations at the last inspection and continues to be a breach at this inspection. It had been identified that emergency lightening was not working but this had not been fully repaired.

At the time of the inspection people had their needs met by sufficient numbers of staff. The provider had recently employed new staff and when there were shortfalls agency staff were employed. However, we were told there had been a long period of time in 2016 when there had not been enough staff and although this did not have a direct impact on people; it had impacted on the other aspects of the service including audits. There were quality assurance systems in place which included reviewing and updating care plans, audits, health and safety checks, but these had not been consistently undertaken by the registered manager due to other work pressures. Audits had not identified some shortfalls that were identified during the inspection.

Staff numbers were based on people’s needs, activities and health appointments

Since the last inspection many of the established staff team had left the service. They said they found this ‘unsettling and confusing’ and were unsure ‘what was happening’. People told us that they were not going out as much as they used to and missed going places and doing different activities. People were involved in some activities which they enjoyed. Some people were able to go out daily and do what they wanted to in the local area. People did art and crafts, as well as other leisure activities within the service.

Established staff had built up relationships with people and were familiar with their life stories, wishes and preferences. Staff knew how people preferred to be cared for and supported and respected their wishes. People were getting to know the new staff and visa versa so that new positive relationships could develop. Contact with people’s family and friends, who were important to them was well supported by staff.

Before people decided to move into the service their support needs were assessed by the registered manager to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan contained information that was personal to them.

People felt safe in the service. Staff understood how to protect people from the risk of abuse and the action they needed to take to report any concerns in order to keep people safe.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

The way people received their medicines had changed and improved since the last inspection. Each person was now supported to be more independent when taking their medicines and their dignity was respected when they were given their medicines.

At the last inspection the provider had not taken all the necessary steps to make sure all staff were suitably qualified, competent skilled and experienced to work with people, at this inspection improvements had been made. Staff had completed induction training when they first started to work at the service and had gone on to complete other basic and specialist training provided by the company.

Staff had support from the registered manager to make sure they could care safely and effectively for people. Staff said they could go to the registered manager at any time and they would be listened to. Staff had received regular one to one meetings with a senior member of staff and an annual appraisal.

People said that they enjoyed their meals. People were offered and received a balanced and healthy diet. People had support to manage their physical and mental health needs.

The complaints procedure was on display in a format that was accessible to people. Feedback from people, their relatives and healthcare professionals was encouraged and acted on wherever possible. Staff and people told us that the service was well led and that the management team were supportive and approachable. They said there was a culture of openness within Phoenix House which allowed them to suggest new ideas which were often acted on.

At the last inspection the service was rated ‘Requires improvement’. Although there had been changes in some areas there continued to be breaches of regulations and the rating remained at ‘Requires improvement’.

We found continuous breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and new breaches of the regulations. You can see what action we told the provider to take at the back of the full version of this report.

Improvements had been made to the care planning process following our last inspection. Everyone now had a care plan, including risk assessments, detailing their needs and giving up to date guidance to staff.

The quality assurance process had been improved. Regular monitoring, audits and checks by the provider ensured the service was safe. People's views about the service were being sought and acted on.

People's hobbies and interests were supported and people had support to access the community and take part in community based activities. People were supported to plan their holidays and days out.

People maintained good health and mental health because the service worked closely with health and social care professionals. The home was safe and well maintained and suited people's needs.

Checks were made on staff, as part of the recruitment process, to make sure that people were safe and supported by appropriate people. One person told us 'The staff are very nice, they try to be helpful.'

We spoke with three people living at the home. One person told us that they did not want to live at the home. Another told us that they were happy and had chosen all the possessions in their room. We saw limited interaction between staff and people.

We found that there were care plans, health files and person centred plans in place for most people that used the service and that these were regularly reviewed and changes made as necessary but this was not consistent.

The manager was not available at the time of our visit and so we spoke to staff and a visiting manager who was present. Not all staff records were available for us to see and we saw gaps in training for staff. We saw that the service had some methods to records peoples views about quality.