First inspection of Pheonix Healthcare found breaches of Regulations 11, 12, 17 and 18 around consent/MCA, risk assessment, governance and staff training/competency, with late and shortened visits, no registered manager and inadequate audit follow-up. Care was rated Good with positive feedback about kind, dignified staff, but overall the service requires improvement.
Concerns (15)
critical
Missed or late visits
: “Records we reviewed showed some visits were two hours later than planned, and as short as 10 minutes, which were not in accordance with the contracted package of care.”
criticalCare planning: “One person had missing risk assessments which included medicines management, personal care, moving and handling and risk of malnutrition and dehydration.”
criticalStaff training: “The training matrix did not list training about mental capacity, and there was no evidence of catheter awareness training.”
criticalStaff competency: “Some staff did not have the knowledge and competencies required to effectively provide support to people. This was a breach of Regulation 18.”
criticalConsent / capacity: “The provider had not documented who was able to make decisions for themselves, and who required best interest decision making. This was a breach of Regulation 11.”
criticalGovernance: “The service did not always effectively assess, monitor and improve the quality and safety of the service. This was a breach of Regulation 17.”
criticalLeadership: “There was a rapid turnover of managers at the service... the service had no manager registered and no application was received.”
moderateSafeguarding: “A staff member we spoke with was not aware of 'self-neglect' as a type of abuse... This had not been identified by the service prior to inspectors raising the potential increased risk.”
moderateSupervision / appraisal: “The nominated individual told us at the site visit no one was responsible for completing spot checks or supervisions with staff.”
moderateRecord keeping: “Personnel files did not always contain all of the required information which must be in place at the point of staff employment to ensure only 'fit and proper' persons provide personal care.”
moderatePerson-centred care: “Person centred language was not always used in people's daily notes... Most of the notes were focused on the tasks that were completed with little to no information about the person's physical, emotional or social wellbeing.”
moderateEnd-of-life care: “There was a lack of information on file for people's end of life preferences... Section one of the DNACPR 'discussed with person/relevant other' was left blank.”
minorMedication management: “Some staff had competency assessments. We advised the nominated individual that staff required competency checks completed by a competent assessor.”
minorComplaints handling: “It also provided CQC contact details to share concerns but did not provide information about people's right to complain to an Ombudsman.”
minorCultural competency: “There was no information about whether the service tried to match same language speaking staff or having the written care plan translated in order for the person to understand their care plan.”
Strengths
· People and relatives said staff were kind and caring; provider maintained a log of compliments
· People's independence, dignity and privacy were respected and promoted
· Adequate supplies of personal protective equipment and infection control training in place
· Incidents and accidents were recorded and investigated appropriately
· Medicines administration records were satisfactorily completed
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving careRequires improvement