Phoenix Healthcare

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated Inadequate. We identified a breach of the regulations relating to Good Governance. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

This service scored 25 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff described a workplace where communication was poor, concerns were ignored, and leadership was unclear. Several care staff told inspectors they did not know who the registered manager was and had no understanding of the service’s goals or priorities.

A lack of clear expectations and shared values contributed to unsafe practice and inconsistent care. Leaders did not communicate effectively, and team meetings were either not held or not recorded. The only meeting record produced was undated and attended by five staff, demonstrating an absence of meaningful cultural direction.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Governance systems were either not in place or not detailed. Leaders failed to identify or respond to risks such as staff working without DBS checks, staff with poor communication skills administering medicines, and 2:1 care being delivered by 1 staff member.

Audits lacked depth, trend analysis, or meaningful action. Leaders failed to investigate concerns raised by staff or families, including allegations of staff being unwilling to complete personal care tasks or treat colleagues respectfully. Supervision records were missing, unsigned or incomplete, showing leaders did not maintain proper oversight of competency or performance.

Staff did not feel they could speak up and their voice would be heard.

The provider did not foster an environment where staff felt able to speak up safely or confidently. Staff told inspectors their concerns about pay, unsafe practice, and colleague behaviour were routinely dismissed or ignored. Evidence provided through WhatsApp messages and emails showed staff repeatedly raising issues which were not followed up.

One staff member reported feeling belittled by colleagues during supervision and stated this impacted their ability to work safely; however, the provider took no action. Staff described feeling unsupported, with some crying and distressed during calls with inspectors due to late or missing wages and unresolved complaints.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Some staff told us they did not feel respected or treated fairly. Staff reported they were not always paid correctly or on time, which caused significant financial stress and worry. Some staff told us this affected their ability to work and made them feel undervalued and unsupported. These issues impacted staff groups contributing to a culture where staff felt they were not treated fairly. This contributed to low morale, poor communication and an unsafe working culture, which in turn affected the quality and consistency of care people received.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were ineffective. Leaders failed to establish or operate systems to monitor quality, safety or performance. Key risks including missed calls, lack of DBS checks, medication errors, poor personal care and staff shortages, were not identified or mitigated.

Auditing was ineffective and lacked detail, analysis or learning.

Staff were not paid accurately or on time, resulting in distress and staff leaving the organisation, which in turn worsened continuity of care.

Recruitment was unsafe and unsustainable, with staff working without DBS clearance for months. Leaders were unable to demonstrate safe oversight placing people at significant risk.

The provider did not understand their duty to collaborate and work in partnership, so services did not work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

External professionals raised concerns about unsafe care including missed or late calls, unsafe manual handling, untrained agency staff supporting people with complex needs and failure to provide required 2:1 support.

These issues were highlighted, but there was no evidence these concerns were investigate or analysed or used to improve people’s outcomes.

The provider did not understand their duty to collaborate and work in partnership, which meant services did not operate smoothly for people. They did not share information or learning with external partners, and they did not work together to improve practice. External professionals raised repeated concerns about unsafe care, including missed or late visits, unsafe manual handling, untrained agency staff supporting people with complex needs, and failures to provide required two‑to‑one support. Although these concerns were highlighted many times, there was no evidence they were investigated, analysed or used to drive improvements in people’s care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Concerns raised internally and externally were not analysed or used to drive change. The audit process was ineffective, and no evidence of learning or reflective practice was shared with staff.

Issues such as poor communication, unsafe practice and inappropriate staff allocation had been raised many times but was not addressed.