CQC report explained · a residential care home
What the CQC found at Phoenix Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were not always enough staff to keep people safe or provide the commissioned support. Inspectors also found delays or gaps in safeguarding referrals, risk information, repairs and learning from incidents.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was carried forward.
- Well-led?
- Requires improvement
- Management audits and incident reviews did not always identify risks or lead to timely improvements. The governance framework was not effective enough to consistently ensure the quality and safety of care.
What inspectors found, November 2020
Rated Requires Improvement; inspectors found concerns about staffing, risk management, incident reviews and governance, although medicines and infection control were generally managed safely.
This was an unannounced focused inspection on 01 October 2020. Inspectors looked only at Safe and Well-led because CQC had received concerns about safety. They spoke with people, staff, managers, social workers and others, and reviewed care records, incident reports, medicines records, staffing information and management checks.
The home was not always safe. There were concerns about staffing levels, safeguarding referrals, risk information, repairs and learning from incidents. Staff knew how to recognise abuse, but some were not confident about raising concerns. Medicines were given safely and infection control arrangements were generally effective.
The home was not always well-led. Management checks and incident reviews did not always identify or act on risks. The provider's governance arrangements were not effective enough to ensure safe care and timely improvements. This breached Regulation 17, Good Governance.
The overall rating fell from Good at the previous inspection, published in March 2019, to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other three questions were not inspected at this visit, so their previous ratings were used.
Medicines
Medicines were given at the right time. Staff responsible for medicines were trained and had their competence checked.
“Staff responsible for people's medicines were trained, knowledgeable and had their competency checked, to ensure safe practice.” from the report
Infection control
Inspectors were assured that the home had effective infection prevention measures, including arrangements for visitors and personal protective equipment.
“We were assured the provider had effective measures for infection prevention and control (IPC) at the service, to protect people from the risk of a health acquired infection through cross contamination.” from the report
Caring relationships
People and relatives were generally happy with the care. Staff were observed to understand people's personal needs and preferences.
“The interactions we observed between people and staff were often person-focused.” from the report
Working with other professionals
The provider worked with health and social care professionals to support people's longer-term health, equipment and care needs.
“The provider worked in partnership with relevant authorities and external health and social care professionals to help inform and agree people's care.” from the report
Staffing levels
seriousThere were not always enough staff to keep people safe or provide the support that had been commissioned. Staff also reported insufficient break times.
“There were not always enough staff to fully ensure people's safety or for people to receive the level of support commissioned for them.” from the report
Risk and care records
needs fixingCare plans did not always give staff accurate information about people's care and safety needs. The home had not always considered how new admissions might affect people already living there.
“People's care plans did not always inform staff of their care and safety needs.” from the report
Governance and oversight
seriousThe provider's checks and action plans did not always lead to clear, timely improvements, including in staffing, incident reporting and environmental safety. This was the subject of a regulatory breach.
“The provider's governance framework was not always effective to consistently ensure the quality and safety of people's care, or to ensure pro-active, timely service improvement when needed.” from the report
Raising concerns
needs fixingSome staff were not confident about raising safety concerns because they feared blame or reprisal. The whistleblowing policy did not give adequate support or information.
“Staff were not always confident to raise any safety concerns they may have relating to people's care, for fear of reprisal.” from the report
- 01What staffing levels are in place now, and how do you cover shifts when there are absences?
- 02How are safety incidents reviewed now, and how do you show that lessons have led to changes?
- 03How are care plans and risk assessments checked when a person moves in or their needs change?
- 04What action has been taken to meet the Regulation 17 Good Governance requirement?
- 05How can staff and families raise safety concerns, and what protection is provided to people who speak up?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 13 November 2020 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, March 2019
Phoenix Lodge was rated Good overall; inspectors found kind, person-centred support, with some improvements needed in recruitment checks and repairs.
Inspectors made an unannounced visit on 5 March 2019. They spoke with seven people, two relatives and staff, and checked care records, medicines and management documents. The service supported 16 people across three supported living settings.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, received their medicines correctly and were treated with kindness and respect. Staff supported people to make choices, build skills, access the community and maintain their independence.
The report says the service met legal requirements. It also found some areas to improve. These included checking recent care references more fully, managing periods when staffing had felt stretched, and repairing or redecorating some areas. The previous inspection, published in July 2016, also rated the service Good.
Safe medicines support
Inspectors found that people received the right medicines at the right times. Staff were trained and their competency was checked.
“People received the correct medicines at the appropriate times.” from the report
Respect and dignity
People were treated politely and with respect. Staff understood how people communicated, including through body language, eye contact and simple sign language.
“People were treated with dignity and respect.” from the report
Choice and independence
Support focused on helping people gain or maintain skills and make their own choices. People were supported to take positive risks and lead active lives.
“The emphasis of support was towards enabling people.” from the report
Personalised support
Care plans covered people's health, activities, finances, friendships and social inclusion. Staff knew people's preferences and responded when their needs changed.
“Support plans were person centred, up to date and reviewed regularly.” from the report
Learning from incidents
The service investigated accidents and incidents. After a choking episode, staff received specialist training and discussed how to respond if it happened again.
“When something went wrong action was taken to ensure that lessons were learnt to help prevent the risk of recurrence.” from the report
Recruitment checks
needs fixingRecruitment procedures were safe overall, but inspectors said the service needed to make sure all recent care references were obtained when checking staff suitability.
“The robustness of references could be improved to ensure that all recent care references were sought to ensure staff suitability to work with vulnerable people.” from the report
Staffing had sometimes felt stretched
needs fixingThe service had recently recruited more staff. Staff said staffing levels had felt stretched at times in the previous few months.
“staffing levels as at times, in the last few months, it had been "stretched.” from the report
Repairs and redecoration
minorThe communal lounge and one person's en-suite needed repair and redecoration. The report says this had been reported and was awaiting decorators.
“The communal lounge in the Lodge and one person's en-suite were in need of repair and redecoration.” from the report
- 01Have all recent care references been obtained and checked for current staff?
- 02How do you make sure staffing levels remain safe when staff are absent or demand is higher?
- 03Has the communal lounge been repaired and redecorated?
- 04Has the en-suite needing repair and redecoration now been put right?
- 05Who is currently managing the service, and has the manager's CQC registration application been completed?
This was an unannounced inspection of personal care and support in three supported living settings; CQC did not regulate the housing or premises, and the previous overall rating from July 2016 was also Good. This explanation was written from the published report of 16 March 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 Lodge
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- November 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
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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