Phoenix Care

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.

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

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of legal regulations in relation to governance and oversight. Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​The provider was also found to have breached regulations in relation to displaying their rating.

This service scored 57 (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 had a clear vision and values which were communicated to staff through a staff handbook and regular guidance. Staff were able to describe the provider's person-centred ethos and explain how this informed their practice. One staff member told us, "We are person-centred."

People and relatives' feedback was consistent with this approach. They told us staff treated them with kindness, dignity and respect, involved them in planning their care, and supported them to maintain their independence.

Most staff told us they felt supported by managers and were able to raise concerns or seek advice when needed. People and relatives also spoke positively about communication with the registered manager and felt listened to when issues were raised.

Leaders did not always demonstrate a sufficient understanding of regulatory requirements, and opportunities to learn from previous assessments had not always been fully embedded into practice. Leaders had not recognised their own development needs or sought appropriate support, challenge or independent scrutiny to strengthen oversight of the service. This contributed to gaps in governance and quality assurance, which limited leaders' oversight of some aspects of the quality and safety of the service.

However, leaders were open, transparent and receptive to feedback. Managers knew people well and demonstrated a person-centred approach to care and support. Staff spoke positively about the management team, with one member of staff telling us, "Boss is one of us, part of the team."

This meant leaders had developed positive and inclusive relationships with people and staff. However, leadership arrangements were not always effective in providing the oversight and challenge needed to identify issues promptly and drive continuous improvement.

The provider promoted a positive culture where people and staff felt able to speak up and have their views heard. Staff told us they were confident raising concerns, and the provider had a speaking up policy in place. People did not raise any concerns about sharing feedback or expressing their views.

The provider did not always demonstrate that it promoted an inclusive and fair culture for all staff. Staff feedback was mixed regarding equality and fairness in the workplace. While some staff felt supported, others told us the type of employment contract they held affected the level of flexibility available to them. Some staff felt colleagues received greater flexibility or adjustments to accommodate their individual circumstances. This indicated staff experiences of fairness and inclusion were not always consistent across the workforce. However, the manager provided examples of agreeing extended periods of leave to support staff when required, and the provider had an Equality, Diversity and Inclusion (EDI) policy in place.

This meant the provider had taken steps to promote equality and inclusion, although not all staff had a consistent experience of these arrangements in practice.

The provider did not have effective governance arrangements to ensure the quality and safety of the service. Systems for recording safeguarding concerns were in place; however, oversight was not effective. Safeguarding records did not consistently evidence investigation outcomes, actions taken or learning identified, and the registered manager told us concerns could remain open for extended periods without updates.

The provider failed to establish effective systems to assess, monitor and improve the service. Although audits and quality assurance processes were in place, they could not demonstrate these had been consistently completed or were effective. The registered manager and deputy manager acknowledged greater oversight was required. As a result, significant shortfalls in risk management, care planning, medicines management, Mental Capacity Act processes, staff competency, recruitment and record keeping had not been consistently identified or addressed.

Delays transferring information to a new electronic care system resulted in gaps and inconsistencies in records, with important information about people's health conditions, risks and support needs not always transferring and staff not always having access to this information.

Professional boundaries were not always clear. Tasks had been delegated to key workers and personal assistants without sufficient oversight or assurance of competence. Monitoring of complaints and regulatory correspondence was also ineffective. For example, the provider failed to respond to an Information Commissioner's Office (ICO) request within the required timeframe, demonstrating weaknesses in governance and regulatory oversight.

In addition, we found the provider's CQC ratings were not displayed at the registered office or on the provider's website. The website was discussed with managers during the first assessment visit, and they agreed to rectify the issue promptly; however, the ratings had still not been displayed correctly at the time of our second visit. These failings demonstrated the provider had not established effective systems to assess, monitor and improve the quality and safety of the service, manage risks, maintain accurate records or ensure learning was embedded. As a result, the provider could not be assured people consistently received safe, effective and well-managed care.

The provider demonstrated a proactive approach to collaboration and partnership working to support people's care and treatment.

Managers told us they worked closely with a range of professionals, including social workers and occupational therapists, to help ensure people received coordinated and continuous care. The provider also signposted people to relevant community and charitable services and supported them to access healthcare appointments, community groups and social activities. Staff described supporting people to attend walking groups, cycling clubs, church gatherings, day centres and local shopping trips.

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

The provider had invested in developing electronic systems to support the delivery and oversight of care, demonstrating a commitment to innovation. However, the system was not always being used to its full potential and did not consistently contain all the information required to effectively monitor and manage people's care.

Shortfalls identified during this and previous assessments indicated that opportunities for learning and improvement had not always been acted upon effectively. Governance arrangements lacked clear structure, and roles and responsibilities were not always clearly defined.

This meant the provider was not always able to demonstrate continuous learning and improvement, limiting assurance that risks, themes and areas for development were consistently identified, monitored and addressed.