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
- People were protected from avoidable harm, with enough staff, suitable risk plans, safe medicine systems and appropriate infection control measures.
- Effective?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- The home had visible and supportive leadership, regular quality checks, staff meetings and systems for identifying and acting on improvements.
What inspectors found, October 2021
Phoenix House is rated Good; inspectors found safe, well-managed care and improvements since the previous inspection.
This was a focused inspection on 7 October 2021. One inspector spoke with staff, gathered feedback from people, relatives and health and social care professionals, and reviewed care, medicine and management records.
The home had enough suitably trained staff. People were supported safely, medicines were managed properly, and staff understood how to respond to safeguarding concerns and distressed behaviour. Infection prevention measures were also found to be suitable.
Inspectors found positive leadership, regular checks and a supportive staff culture. The home had improved from Requires Improvement at the previous inspection in December 2019 and was no longer in breach of Regulation 12.
Only Safe and Well-led were assessed during this visit. The ratings for the other areas were carried forward from the previous comprehensive inspection.
Enough staff
Inspectors found sufficient staff to meet people's needs. Staff said they had time to support and spend time with people.
“People were supported by sufficient numbers of suitably trained staff.” from the report
Safe medicines
Medicine storage, records, staff training and checks were found to be safe. There were clear instructions for medicines prescribed as required.
“We reviewed the medicine administration records (MAR) for people and saw that they were being completed properly and signed by the competent person administering the medicines.” from the report
Positive culture
People appeared comfortable with staff. Inspectors saw laughter, interaction and support tailored to people's communication needs.
“The service promoted a positive culture and the registered manager was a role model for staff.” from the report
Learning from incidents
Incidents were reviewed and used to consider whether practice could be improved. Behaviour-related incidents could also be reviewed by a specialist staff member.
“Accidents and incidents were used as an opportunity to learn and improve practice.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you make sure there are enough staff at night to meet my relative's needs?
- 02What guidance will staff follow if my relative becomes distressed or anxious, and how will you review whether it is working?
- 03How will you decide when to give any medicine prescribed for my relative to take as required?
- 04What activities outside the home are now being planned as restrictions have eased?
- 05What are the current ratings and latest findings for Effective, Caring and Responsive, which were not assessed at this visit?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 23 October 2021 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, December 2019
Rated Requires Improvement; inspectors found kind, personalised care but unsafe night staffing and weaknesses in management.
The inspection was unannounced and took place on 5 and 12 November 2019. One inspector observed care, spoke with staff, reviewed records and spoke with relatives and health and social care professionals.
The home was rated Good for Effective, Caring and Responsive. Inspectors found that people were treated with compassion, received personalised support, had their health needs supported and were helped to take part in activities.
The home was rated Requires Improvement for Safe and Well-led. There were not always enough staff at night, particularly when two staff were supporting someone having a seizure. A medicines room had also been left unlocked. The home was previously rated Good in May 2017.
Kind and respectful care
Inspectors found that people were treated with compassion and that staff promoted privacy, dignity and independence.
“People were treated well and with compassion. Systems such as role modelling, training and monitoring of staff's practice ensured this.” from the report
Personalised support
Staff knew people well and understood their individual communication styles, needs and preferences. Support plans were detailed and regularly reviewed.
“Each person had a detailed, well written support plan, which showed their needs, any support required and individual preferences.” from the report
Health and staff support
People received support from a range of health professionals. Staff had relevant training, regular one-to-one meetings and support from management.
“People received a range of support to meet their health care needs. This included support from professionals such as the speech and language team, behavioural specialist, psychiatrist and community nurses.” from the report
Activities and community life
People were supported to go out regularly and take part in activities such as arts and crafts, cooking and visits to local places.
“People were supported to go out on a regular basis. This included shopping, to the village coffee shop or places of interest.” from the report
Not enough staff at night
seriousNight staffing was not consistent enough to supervise everyone safely when two staff were needed to support a person having a seizure. Inspectors said this created an increased risk of harm.
“At night, there were not always enough staff to safely meet people's needs.” from the report
Medicines room left unlocked
needs fixingA person entered the room where medicines were stored because the door had been left unlocked. No medicine was swallowed, but inspectors found there had been a risk to the person's safety.
“This involved a person going into the room where medicines were stored, as staff had left the door unlocked.” from the report
Provider did not act quickly enough
needs fixingThe provider knew that night staffing was insufficient but had not resolved it. The home had also been without a tumble drier for over two weeks without a delivery date.
“As part of their auditing, the registered manager had identified staffing levels were insufficient at night. However, the provider had not addressed this to ensure people's safety.” from the report
- 01What night staffing arrangement is now in place, and is the 7pm to 2am shift provided consistently?
- 02What is the plan if two staff are supporting someone during a seizure and other residents also need supervision?
- 03What changes were made after the medicines storage room was found unlocked?
- 04How are audits now checked to make sure identified safety problems are acted on promptly?
- 05How will my relative's communication style, preferences and support plan be kept up to date?
This was a planned inspection covering all five CQC questions; the previous Good rating was published on 26 May 2017. This explanation was written from the published report of 31 December 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
4 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 December 2010.
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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