Phoenix Healthcare

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Requires Improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We identified a breach of Safe Staffing as the provider failed to ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet people’s needs safety.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not demonstrate a proactive or positive culture of safety based on openness and honesty. They did not always listen to concerns about safety, and concerns were not consistently investigated or reported. This meant lessons were not learnt or embedded to support continuous improvement or safe practice.

A person told us they had raised complaints with the management team about their care but there was no evidence these had been investigated. Relatives told us they knew how to raise concerns or make a complaint and were aware of the complaint’s procedure.

The provider investigated safeguarding concerns. However, staff told us they did not always know who to raise concerns with, and when they did raise concerns, they were not updated with any outcome, and there were no records of lessons learned.

When people’s needs changed, care plans and risk assessments were not always updated. For example, when people developed skin damage and the district nurse was involved. The provider did not update care plans and risk assessment with the change of needs.

The provider did not foster a culture where concerns were always recognised investigated or used to improve care.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.

Staff did not always work closely with healthcare professionals to monitor health needs or respond to changes. They depended on people or relatives to inform the service of any changes in needs, highlighting a lack of systems for timely escalation and risk management.

One person told us, “My transition went very well thanks to [registered manager]; I was very pleased with the support I received.” However, another relative told us they dealt directly with healthcare professionals, including GPs for medication reviews. They said, “I informed the manager of any changes in care to [family member] I go to the doctor’s reviews, so I know what’s going on because I don’t want anything to be missed around [family member] care.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People and their relatives told us they did not always feel safe with agency staff or staff who were not their usual carers. One person said, “The agency staff don’t know my needs I have to tell them what to do.” A relative told us while their family member’s regular carers were kind and knew their needs well, agency staff and other unfamiliar carers relied on them to explain what needed to be done.

Staff demonstrated an understanding of their roles and responsibilities in safeguarding people from harm. They were able to identify signs of potential abuse and were familiar with the procedures for reporting concerns.

Some safeguarding concerns had been discussed in Multidisciplinary team (MDT) meeting. MDT is a group of professionals from different disciplines who work together to review concerns, share information and make coordinated decisions about a person care.

There were systems in place to investigate safeguarding concerns, and the registered manager demonstrated an understanding of their safeguarding responsibilities.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People's risks were managed and mitigated to keep them safe. People and relatives told us they were involved in their care and how they wanted to be supported to manage their assessed risks. One person said, “My regular carer [staff name] is very good they know exactly what I need help with.” One relative said, “I am involved in all decisions made about my [family member’s] risks.”

Staff understood people’s individual risks and how they needed to support people to remain safe. One staff member said, “I look at the care plan, so I know what the person needs support with, and I also ask them each time I visit too.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental risk assessments of people’s homes were completed prior to staff delivering care and support. This process helped to identify and mitigate potential environmental hazards, promoting the safety and wellbeing of both people using the service and staff.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People, relatives and staff told us there were not always enough staff to meet people’s needs. People and relatives also told us they were not consistently informed about which staff member would be attending, and sometimes they were left without timely visits, resulting in relatives having to step in to provide care. One person told us, “Most of the good staff have left due to not getting paid. I am mainly having agency staff who don’t know my needs.”
One staff member told us, “Not all staff especially agency carers have the skills to deal with the complex people.”

Overall, staffing arrangements were unsafe and unreliable, with shortages, poor skills mix and a lack of support and supervision, resulting in people not consistently receiving the care they needed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Staff had received infection and prevention and control training but did not always have access to equipment such as gloves if needed. One person told us, “Sometimes they run out of gloves.” A staff member told us, “I have let the office know several times that we were running out of gloves, but we didn’t receive any and when they did get some, they weren’t the correct gloves for delivering personal care.”

There was no system in place to ensure infection control equipment was monitored, restocked or supplied consistently.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning their medicines support.

Staff had received medicines training, competency checks had been completed, and there was evidence that medicines audits were taking place. However, the high reliance on agency staff, along with some staff not having English as their first language, meant medicines were not always managed safely or consistently. One person told us, “I asked a carer about my medication and realised that although their first language wasn’t English, they could speak English but could not read my medication or the MAR chart and were relying on me to tell them what I needed; this worried me.” This created an increased risk of errors and reduced oversight of people’s medicines.