Phoenix Care (Havering) Limited received a Good rating overall following a focused inspection of Safe and Well-led domains, with improvements noted in risk assessment robustness and governance since the previous inspection. No regulatory breaches were identified, and people and relatives expressed consistently positive feedback about the quality and reliability of care.
Strengths
· Risk assessments in place for falls, personal care, dehydration and skin integrity with clear staff actions
· Digital call monitoring system used to verify staff attendance and duration at care calls
· Medicines managed safely with support plans, MAR records and staff competency assessments
· Safe recruitment practice with DBS checks, identity verification and references obtained
· Audit systems improved since last inspection covering care plans, risk assessments, medicines and staff files
Quality-Statement breakdown (13)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Ensuring consent to care and treatment in line with law and guidanceGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving careGood
Phoenix Care (Havering) Limited was rated Good overall at its first CQC inspection, with safe, effective, caring and responsive domains all Good, but Well-led requiring improvement. The principal failures were incomplete risk assessments for individuals with identified clinical risks and quality assurance systems that failed to detect these shortfalls.
Concerns (4)
moderateCare planning: “Some risk assessments had not been completed for some people. Records showed that some people were at risk of falls. One person had osteoporosis... Risk assessments had not been completed on this.”
moderateGovernance: “Audits were carried out on people's care plans, risk assessments and medicine records. However, this had not identified the shortfalls we found with risk assessments.”
moderateRecord keeping: “Although the medicines audits identified gaps on people's medicines records, this did not detail if the gaps were a recording keeping error or if medicines had not been administered.”
minorSupervision / appraisal: “Formal 1:1 supervisions of staff had not been completed regularly in accordance to the providers supervision policy, to ensure staff felt supported at all times.”
Strengths
· Medicines were managed safely with accurate MAR records, regular audits and spot checks by the registered manager.
· Pre-employment checks including DBS, references and employment history were completed in full for all staff.
· Staff received essential and specialist training including falls, pressure ulcers, dementia and challenging behaviour.
· Staff were aware of safeguarding procedures and knew how to identify and report abuse internally and externally.
· Staffing arrangements ensured timely visits with travel time built in, a digital monitoring system and on-call cover.
Quality-Statement breakdown (19)
safe: Risk assessmentsRequires improvement
safe: Medicines managementGood
safe: Recruitment and pre-employment checksGood
safe: SafeguardingGood
safe: Staffing and visit attendanceGood
safe: Infection controlGood
effective: Staff training and inductionGood
effective: Mental Capacity Act and consentGood
effective: Needs assessment and care planning
Good
effective: Supervision and support of staffRequires improvement
effective: Access to healthcareGood
caring: Relationships and person-centred approachGood
caring: Involvement in decision makingGood
caring: Privacy and dignityGood
responsive: Person-centred care plansGood
responsive: Complaints handlingGood
well-led: Quality assurance and governance systemsRequires improvement
well-led: Record keepingRequires improvement
well-led: Staff and people feedback / culture of improvementGood