Phoenix Care

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• 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

The provider was previously in breach of legal regulations in relation to Safe care and treatment, and fit and proper persons employed. Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​

This service scored 47 (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 always demonstrate a proactive and positive culture of safety or consistently use incidents and concerns to identify learning opportunities and drive improvement. Systems in place to record, review and learn from safety-related incidents were not always effective. For example, records showed a person had sustained a scald injury from bath water; however, there was no evidence the incident had been fully reviewed or that any resulting actions, learning, or outcomes had been identified, recorded and shared with staff. This meant the provider could not always demonstrate that incidents were thoroughly investigated or that learning had been used effectively to reduce the risk of similar incidents occurring in the future.

However, staff understood their responsibilities for reporting concerns and could clearly describe the processes they would follow to escalate incidents and safety issues. People and relatives, we spoke with did not raise concerns about their safety or the care they received.

The provider did not work effectively with people and healthcare professionals to establish and maintain safe systems of care. Risks to people's health, safety and wellbeing were not always adequately assessed, monitored or managed.

At our last assessment the provider had failed to ensure systems were in place to demonstrate safety was effectively managed.

Care plans did not contain clear information about people's needs and associated risks. For example, risks relating to 1 person's diabetes had not been fully assessed. Records did not specify the type of diabetes and there was no diabetes risk assessment, care plan, or guidance for staff regarding the signs and symptoms of hypoglycaemia or hyperglycaemia, associated risks, required interventions, or escalation procedures.

Another person had a diagnosis of epilepsy; however, care records did not include information about the type of epilepsy, how the condition affected them, known seizure triggers, seizure presentation, required interventions, post-seizure care, or escalation procedures. There was no epilepsy care plan or risk assessment to guide staff on how to safely support the person or respond appropriately in the event of a seizure. This was not in line with recognised NICE(National Institute for Health and Care Excellence) guidance, which states that people with epilepsy should have care that is planned and coordinated, with clear information available to support the safe management of their condition and associated risks. This meant the provider could not be assured that people were receiving safe and effective support in relation to their long-term health conditions, or that staff had sufficient guidance to respond appropriately in the event of deterioration or an emergency.

One staff member demonstrated a basic understanding of a person's diet-controlled diabetes and the importance of monitoring their dietary needs. People did not raise any concerns about systems and transitions into the service.

The provider did not always work effectively with people or relevant healthcare partners to understand what being safe meant for individuals or how to protect them from abuse, avoidable harm, and neglect.

The provider had not acted in accordance with the Mental capacity act (MCA). Mental capacity assessments were not decision-specific and did not reflect the decisions required in relation to people's care and treatment.

For example, concerns had been identified regarding 1 person's ability to manage their finances and their vulnerability to financial abuse or exploitation. Records contained conflicting and outdated information about the person's understanding of their finances and level of independence. While care records stated the person managed their finances independently, the registered manager told us they were largely reliant on another person and had limited awareness of their financial circumstances. Despite these concerns, there was no decision-specific mental capacity assessment relating to financial management, and no evidence that appropriate safeguards had been considered or implemented.

As a result, the provider could not demonstrate that decisions relating to the person's finances had been made in line with the principles of the MCA or that adequate measures were in place to protect them from potential harm.

The provider had a safeguarding policy in place, staff had completed safeguarding training, and staff understood how to recognise and report concerns. People told us they felt safe and raised no concerns about the care and support they received.

The provider did not always work effectively with people to understand and manage risks or ensure care and support was delivered in a safe and person-centred way.

Risk assessments and care plans were not always comprehensive or consistent. We found gaps in guidance relating to falls, mobility and mental health risks. Falls assessments did not always clearly describe preventative measures, how staff should respond following a fall, or consider factors that increased the risk of falling. Records relating to mobility needs were inconsistent, with conflicting information about the level of support people required. In addition, mental health risks had not always been assessed. This meant staff did not always have clear, accurate and up-to-date information to support people safely and manage identified risks effectively.

Staff described involving people in decisions about their care, and provided examples of working with people, families to reduce risks while supporting independence.

The provider did not always identify and manage risks within the care environment.

The registered manager told us environmental risk assessments were completed for each person’s home or environment. However, these did not always consider or link to associated risks identified through people's care and support needs. For example, one person regularly smoked cigarettes and was known to extinguish them on carpets and upholstered furniture. Despite the associated fire risks, there was no risk assessment or risk management plan in place to identify the hazards, set out control measures, or provide guidance on actions required to reduce the risk of harm.

Professionals told us a recent review of the service had identified the need for Personal Emergency Evacuation Plans (PEEPs) to be implemented for people using the service. PEEPs are individualised plans that outline the support a person would need to evacuate safely in an emergency. Professionals confirmed the provider was engaging with this process and implementing the plans.

Staff demonstrated an awareness of the importance of maintaining safe environments ensuring people’s homes were safe before providing care, using equipment safely, reducing any hazards.

The provider did not always ensure there were enough suitably qualified, competent, skilled and experienced staff to meet people's needs.

Staff had not always received training relevant to the health conditions and care needs of the people they supported, including diabetes, epilepsy and catheter care. The provider was unable to demonstrate that staff had completed refresher training, competency assessments or knowledge checks to assure itself that they remained competent to provide safe care. In addition, the provider could not evidence that staff undertaking delegated healthcare tasks, including catheter care and blood pressure monitoring, had been assessed as competent to carry out these duties safely.

Recruitment processes were not consistently followed. Two staff members had commenced working with people before a Disclosure and Barring Service (DBS) check had been received, and no risk assessments were in place to demonstrate how the associated risks had been considered and mitigated. The registered manager told us they were unaware that a risk assessment was required where staff were working pending receipt of a DBS disclosure.

Newly appointed staff had not completed an induction programme. The provider was unable to provide records of completed inductions, shadow shifts or competency assessments to demonstrate that staff had been appropriately prepared for their roles.

At the previous assessment, we found the provider had failed to operate effective systems to ensure staff were recruited safely.

These concerns mirrored those identified at the previous inspection and demonstrated that sufficient improvements had not been made to ensure staff were appropriately trained, competent and safely recruited. As a result, the provider could not be assured that staff had the necessary skills, knowledge and competence to provide safe and effective care and support.

Staff told us they completed a range of face-to-face and online training and felt they had the skills and knowledge needed to meet people's needs safely. People and relatives also told us staff were well trained.

The provider assessed and managed the risk of infection effectively. Infection prevention and control policies, systems and processes were in place to identify, assess and control risks associated with the spread of infection. Staff told us they had received infection prevention and control training and understood the importance of using personal protective equipment (PPE). People confirmed staff wore appropriate PPE when providing support and when required.

The service did not always ensure medicines and treatments were managed safely and in line with people's needs, capacities and preferences. Medicines management was not consistently safe or effective. Allergy information, medicines assessments and support records were incomplete or inaccurate for some people, and some care records contained incorrect personal information. Medicines intended for morning administration, including medicines used to manage blood glucose levels, were routinely administered later in the day, increasing the risk of adverse effects. Information to support the safe administration of PRN (as required), topical and higher-risk medicines was not always completed, and fire risk assessments had not always been completed for people prescribed paraffin-based emollients.

This meant people were exposed to an increased risk of unsafe medicines management as systems and records did not consistently support the safe administration, monitoring and oversight of medicines.

The manager demonstrated a good understanding of the electronic medicines system, and there were examples of good practice, including multidisciplinary decision-making for covert administration. Staff told us medicines errors were addressed through additional training.