CQC report explained · a residential care home
What the CQC found at Phoenix House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from avoidable harm, there were enough staff and medicines were generally given as prescribed. One handwritten medicines record had not been checked and countersigned correctly, but the manager acted during the inspection.
- Effective?
- Good
- This area was not inspected during this focused inspection.
- Caring?
- Good
- This area was not inspected during this focused inspection.
- Responsive?
- Good
- This area was not inspected during this focused inspection.
- Well-led?
- Good
- The new manager was creating a more positive culture and had an action plan for improvement. The manager was also reviewing restrictions, staff morale and whether the home could meet one person's needs.
What inspectors found, January 2023
Rated Good; inspectors found safe, respectful care and improving leadership, with some records and choice arrangements still needing attention.
This was an unannounced focused inspection. Inspectors visited on 30 September 2022 and reviewed information up to 26 October 2022. They spoke with staff, people using the service, relatives and health and social care professionals. They also observed the home and checked care plans and medicine records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable safeguarding systems and medicines generally given as prescribed. Staff understood how to support people when they were distressed, and physical restraint was used as a last resort.
The new manager had been in post for two months and was working on the home's culture, people's quality of life and staff confidence. Inspectors found some areas still being improved. These included one handwritten medicines record, some mental capacity assessments and one person's impact on other people's use of communal spaces.
Enough staff
Inspectors saw that staffing levels met people's needs. Extra night staff had been provided for a person with epilepsy while further support was being arranged.
“There were enough staff to meet people's needs.” from the report
Safe support
Staff understood safeguarding procedures and how to support people who became distressed. Physical restraint was treated as a last resort.
“Staff used physical restraint as a last resort” from the report
Choice and independence
The home was set up to support people to live independently and make choices. Staff supported people in the least restrictive way possible.
“The service was set up to enable people to be independent and have choice over how they lived their lives.” from the report
Positive leadership
The new manager was working to improve quality of life, reduce restrictions and build a learning culture.
“The new manager was promoting a positive and empowering culture at the service.” from the report
Use of communal spaces
needs fixingOne person's needs meant that other people did not have full choice over how they used communal spaces. The provider was taking action to protect people's freedom.
“one person's needs meant people did not get a full choice over how they used communal spaces.” from the report
Mental capacity records
minorMental capacity assessments were clear but did not cover every decision a person needed to make. The provider had a plan to improve this.
“Mental capacity assessments were in place. These were clear but did not cover each decision the person needed to make.” from the report
Manager registration
minorThere was no registered manager in post during the inspection. The new manager had applied to become registered and the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Has the handwritten medicine administration record issue been fully corrected, and how are medicine records checked now?
- 02How will people make sure they have a full choice over using the communal spaces?
- 03Have the planned mental capacity assessments now covered every decision each person needs to make?
- 04What is the current position on the manager's application to become the registered manager?
- 05How does the home decide whether it can meet a person's needs and protect the wellbeing of everyone living there?
This was a focused inspection of Safe and Well-led only; the other three ratings were not reviewed in this report and the previous overall rating was Good. This explanation was written from the published report of 5 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2019
Rated Good; inspectors found safe, kind and personalised care, with some medicine and record-keeping improvements still needed.
Inspectors visited on 25 March 2019 and spoke with managers, care staff, a healthcare professional and relatives. They reviewed care records, staff files, medicines records and the home's quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from harm, received suitable support with health needs and medicines, and were treated with dignity and respect.
The home had improved since the previous inspection, which rated all five areas Requires Improvement. Inspectors still recommended better detail in daily care records and stronger checks of medicine stocks, but they did not report any breaches of regulations.
Protection from harm
The home had safeguarding policies, trained staff and clear risk assessments. People had plans covering risks such as medicines, behaviour and going out in the community.
“People were protected from avoidable harm and abuse.” from the report
Personalised support
Care plans included people's preferences, communication needs and goals. Staff planned activities such as walks, drives, cinema trips and time in the community.
“People received personalised care which included their preferences and outcomes.” from the report
Dignity and choice
Inspectors found that people were treated respectfully and supported to make choices and remain as independent as possible.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Staff preparation
Recruitment checks were completed, and staff received induction, training, supervision and appraisals. Training covered safety and the specific needs of people using the home.
“Staff were recruited safely and were supported to carry out their role with training, supervision and appraisals.” from the report
Medicine records
needs fixingPRN medicines for one person had not been added to the medicine administration record. Managers corrected the records during the inspection and contacted the pharmacy about future printed records.
“However, we noted that PRN medicines for one person had not been added to the medicine administration record (MAR) sheets.” from the report
Medicine stock checks
needs fixingThe medicine audit did not allow staff to compare stock levels with the records. Inspectors also found a large stock of insulin, which could have been identified by a stronger checking system.
“However, we noted there was no place in the medicines check that enabled the management team to check the amounts of medicines in stock against the records.” from the report
Care record detail
minorDaily notes did not always explain enough about activities, such as where a person went or which film they saw. Inspectors recommended that the home seek advice about record-keeping.
“daily notes did not give enough detail about this.” from the report
Staff consistency
needs fixingRelatives and a healthcare professional reported recent high staff turnover and use of agency staff. They said this had unsettled people, although managers said recruitment was ongoing and there were no current staffing issues.
“Relatives and a healthcare professional noted there had recently been a high turnover of staff and high use of agency staff which was unsettling for people using the service.” from the report
- 01How do you now check medicine stock against the records, including insulin and PRN medicines?
- 02How do you make sure every PRN medicine is listed correctly on the medicine administration record?
- 03How are you keeping staffing consistent and reducing the use of agency staff?
- 04How do daily records now show the details of people's activities and outings?
- 05Have the fire door and glazing works identified in the January 2019 fire risk assessment been completed?
This was a scheduled inspection of the care home covering the premises and care provided, with all five CQC questions rated. This explanation was written from the published report of 18 May 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Phoenix House
3 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- March 2016
Registered with the Care Quality Commission on 2 March 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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