Phoenix Futures National Specialist Family Service

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last inspection we rated this key question as requires improvement. At this inspection the rating has changed to good. This meant clients were kept safe and protected from avoidable harm.
The environment was well furnished, well maintained and fit for purpose. Staff provided care and treatment in a way which made clients feel supported and listened to.
Clients felt they were respected and treated with kindness, and compassion. Clients were treated as individuals and encouraged to be involved in their care and treatment planning.
There were sufficient staff, processes, and equipment in place to maintain the safety of the clients and to meet their needs. Safeguarding was fully embedded throughout the service and the service worked collaboratively with other agencies and referred, shared or escalated concerns as appropriate.
The service demonstrated good practice in relation to medicines management and optimisation.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff knew what incidents to report, how to report them and did so accordingly. Staff understood the duty of candour. They were open and transparent and gave clients and families a full explanation when things went wrong.
Staff received feedback from investigations of incidents, both internal and external to the service. Staff told us that when they reported incidents, they received feedback in several ways including through team meetings, supervision, email and debrief sessions.
Staff developed case studies as a way of further enhancing learning, reflective practice and to continually embed good practice, effective information sharing and continuity of care with external services.
There were no serious incidents recorded during the previous 12 months.
There was evidence of changes being made because of feedback from incidents and client meetings, such as the implementation of domestic abuse support sessions facilitated by Independent Domestic Abuse Services (IDAS) Sheffield. Phoenix Futures National Specialist Family Service also performed trend analyses through their incident reporting system that was fed back to staff in team meetings and supervision sessions. These were also reviewed across the organisation at a serious incident review panel. The ‘Continuous Improvement Plan’ was also updated by managers to evidence learning.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that essential information about the client, such as GP summaries, were received to determine if their needs could safely be met. Staff completed a full assessment for each client prior to admission with a thorough risk assessment carried out to determine if they were suitable for the service.
There was a policy in place with a clearly defined admission criteria included. Clients deemed to be higher risk would not be admitted to the service at that time and staff would work with the individual and other professional agencies to find the most suitable alternative.
Staff involved a wide selection of healthcare and social care services to ensure clients had continuity of safe care, both within the service and post-discharge. This included both NHS and independent support agencies, for example, mental health and practical, therapeutic support.
Each client had an ‘early move on plan’ in place as part of their care. This ensured contact details for appropriate support services were available to the client in the event of an early exit from treatment.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were provided mandatory training in safeguarding adults and safeguarding children and at the time of our inspection the compliance rates were 100% for both. All families receiving care at Phoenix Futures National Specialist Family Service were open to social workers, of which all incidents involving safeguarding were shared.
Staff knew how to make a safeguarding alert and did so when appropriate. Staff could give examples of how to protect clients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
In the last 12 months, staff had made 8 safeguarding referrals to the local authority.
Safeguarding audits were included within incident reporting and learning. These were detailed in trends analysis, incident reviews, serious incident review panel (if required) and filtered down into team meetings and clinical supervision sessions to ensure learning.

We saw evidence of positive multi-agency working with complex child and adult safeguarding teams, children services and independent domestic abuse service (IDAS).

Staff followed safe procedures for children visiting the service. The service actively promoted family contact and re-establishing links with children that were not currently in their mother's care.
Staff did not use restraint at the service. There were some blanket restrictions in place, such as a prohibited and restricted items list which contained appropriate items and was reviewed regularly. Clients agreed to the rules of the unit in the form of an occupancy agreement, prior to admission and were given a welcome pack upon arrival at the service which outlined any restrictions. Rules included set times when mobile phones could be accessed. Families were escorted by staff to access the local community during the early stages of the therapeutic programme, this gradually progressed to peer escort and was also subject to children services approval when care orders were in place.

Mental Capacity Act

94% of staff had received training in the Mental Capacity Act.
Staff we spoke with had a good understanding of the Mental Capacity Act, particularly the five statutory principles.
There was a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff we spoke with were aware of the policy and told us they had access to it.

Due to parental responsibilities, all residents were required to have capacity to independently care for their children, which was evident within the service's exclusion criteria. However, the service demonstrated good awareness for the potential of fluctuating capacity and had policies and procedures in place should clients lack capacity to make specific decisions for themselves.

At the time of the inspection, no clients had any issues with mental capacity.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to clients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 7 care records one of which was a recently discharged client. During the inspection and found that each client had an up-to-date risk assessment in place.
Staff involved clients in care planning and risk assessments, and this started prior to admission on pre-admission assessment calls and meetings.
We saw that clients had an ‘early move on plan’ in place if they decided to, or were asked to, leave treatment unexpectedly. This set out who to contact and what action to take, as well as signposting the client to other support agencies. This plan was devised between staff and clients prior to admission.
Staff communicated effectively with clients so that they understood their care and treatment, including finding effective ways to communicate with clients with communication difficulties.
Staff enabled clients to give feedback on the service through 1:1 sessions, scannable QR codes, feedback and complaints forms, house forums and service user satisfaction surveys.
There were weekly community meetings in place and meeting minutes showed that these were well attended by clients as well as staff. Client feedback was discussed and actioned following each community meeting.
We found the admission criteria ensured that the service only admitted clients whose needs could safely be managed. The service did not admit clients at risk of suicide and self-harm or presenting with current complex mental health needs.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed regular risk assessments of the care environment. There were some blind spots within the care environment which meant staff could not observe all parts of the environment, but staff mitigated these through observations and environmental checks.

Clients admitted were robustly risk assessed around their suitability to reside at Phoenix Futures National Specialist Family Service. This included assessment of their mental health prior to admission and staff explained that if someone was an active self-harm risk or had a recent significant history, they would not be suited to the service and alternative arrangements would be made.
Staff were conscious of the possibility of new risks emerging, especially during the detox and post-partum stages of a client’s admission. They ensured risk assessments were regularly reviewed and that environmental risks were managed accordingly with the use of observations and staff knowledge of individual presentations.
Staff and clients had access to telephones throughout the building. The clinic room was well equipped and organised, with accessible resuscitation equipment and emergency drugs that staff checked regularly.

There were ligature cutters available, staff were aware of their location and how to use them. However, there was no maintenance process in place to replace or sharpen any used cutters. We immediately notified managers of this and were informed that this would be actioned. We have since received an updated ligature cutter process that addressed any maintenance requirements.
The service managed risk and client safety where there was mixed sex accommodation. All clients had their own rooms with shared bathroom and kitchen facilities on the same landing. The admission criteria provided adequate mitigation, and the provider had a risk assessment and policy in place to manage sexual safety.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers had calculated the number of staff required. The number of nurses and support workers matched this number on most shifts. The manager could adjust staffing levels to meet specific demands on the service.
Staff turnover rate was 42% within the last 12 months. Managers within the service explained that this was due to the potential closure of the service at the end of 2024. This meant that staff had started to consider other roles and career development opportunities and subsequently left the service in 2025. A recruitment drive followed and at the time of inspection, there were 3 vacancies outstanding. Where necessary, managers deployed agency and bank staff to maintain safe staffing levels.
Staff sickness was 14% at the time of inspection. Managers informed the inspection team that there were no identifiable trends and that the sickness rate was mainly due to long term sickness due to planned surgeries, and we saw robust plans in place to support staff back to work.
Agency and bank staff employed received a full induction and understood the needs of the service prior to commencing their shift. They were given a tour of the facility and familiarised with emergency procedures and shown where emergency equipment was stored. Managers told us they would always attempt to cover shifts with regular bank and agency staff wherever possible.
Staffing levels allowed clients to spend regular 1:1 time with staff and to attend scheduled group sessions.
Staffing levels rarely resulted in the cancellation of support sessions.
The service provided medical cover to meet the client’s needs through a substance misuse specialist Doctor. Clients were also registered with a local GP for any routine appointments. Staff called the emergency services where clients needed urgent help with a medical need. In the 12-month period preceding our inspection, there were 5 occasions where a client was referred to the local emergency department, 3 of these occasions required an ambulance.
Staff had received and were up to date with appropriate mandatory training. This included first aid training, manual handling, medicines management, naloxone training, safeguarding adults and children and Autism and learning disability training. All training was above 75% compliance.
Equality, diversity and inclusion training did not form part of the mandatory training schedule, instead it was embedded in staffs’ continual professional development programme, which included online training and workbooks, and the service considered and addressed barriers to access for specific communities and those with protected characteristics. At the time of our inspection equality, diversity and inclusion training compliance figures was 93%

The mandatory training programme was appropriate for the client group using the service.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the environment was cleaned regularly. Staff adhered to infection control principles, including handwashing.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Care records and observations showed that staff followed systems and processes to prescribe and administer medicines safely. Staff reviewed each client's medicines regularly and provided advice to clients about their medicines. Clients were prescribed medicines for short periods of time while they completed their detoxification programme. Doctors could review medicines administration remotely.
Staff completed medicines records accurately and kept them up to date. Staff stored and managed all medicines and prescribing documents safely. The treatment room was of a high standard, well organised, clean and with adequate space to carry out physical examinations and discussions regarding medication privately.

There was sufficient stock of emergency medications on the premises at all times, such as naloxone.

Clients were supported through detoxification by a specialist detoxification GP and staff managed client withdrawals in-line with national guidance.

They followed national practice to check clients had the correct medicines when they were admitted or they moved between services.
Where clients gave permission, staff checked with the client’s GP what medicines they were prescribed. Medicines that clients brought in with them were checked in, and any repeat prescriptions were accessible through a local GP.
Staff reviewed the effects of medication on client’s physical health regularly and in line with National Institute for Care and Excellence (NICE) guidance. We found evidence of client’s physical observations being taken, recorded and escalated accordingly.