Phoenix Gold Homecare achieved an overall rating of Good at its first CQC inspection, with staff praised for kindness, consistent personalised care, and safe medicine management. The Well-Led domain requires improvement due to insufficient governance oversight, inconsistent Care Certificate delivery, and failures to notify CQC of safeguarding concerns raised with the local authority.
Concerns (5)
critical
Safeguarding
: “The provider needed to ensure that any issues raised with the local authority around safeguarding also needed to be notified to the Care Quality Commission(CQC).”
moderateGovernance: “Information gathered from audits, 'spot checks' and accident/incident reporting was not collated so that areas for improvement and development were clearly identified.”
moderateStaff training: “There was an induction programme in place and all new staff were required to complete the Care Certificate; however, we found that this was not consistently delivered.”
moderateIncident learning: “The provider and registered manager needed to ensure that when complaints were made consideration was given as to whether any issues raised linked to other procedures such as safeguarding.”
minorComplaints handling: “The procedure was not followed consistently which meant that people were not always made aware of where else they could raise their complaint if they remained unhappy.”
Strengths
· People were protected from risk of harm and received prescribed medicines safely, with regular competency checks and audits.
· Staff were described as kind, caring and passionate, with consistent staffing and personalised rotas shared with people.
· People had detailed, personalised care plans reflecting preferences, cultural needs and communication requirements.
· Effective recruitment practices including DBS checks and employment references consistently followed.
· Positive relationships developed with health and social care professionals including District Nurses and Occupational Therapists.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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 meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Planning and promoting person-centred, high-quality care and support with openness; duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood
Phoenix Gold Homecare's rating dropped from Good to Requires Improvement due to weaknesses in catheter risk management, recruitment reference checks, mental capacity assessments and overall governance oversight. Medicines management, safeguarding, staffing levels, training and partnership working remained positive, and the provider acted promptly to address concerns after the inspection.
Concerns (6)
criticalConsent / capacity: “The policies and systems in the service did not support the assessment of people's mental capacity to determine how and when best interests' decisions were made.”
moderateCare planning: “we found people who had a catheter did not have risk management plans in place to instruct staff on spotting the signs of catheter related risks.”
moderateStaff competency: “staff did not always have a reference from their last known employer, in line with the provider's own recruitment policy, before commencing work at the service.”
moderateConsent / capacity: “we found some consent forms had been signed by family members rather than the person receiving care, which did not demonstrate people had been involved in decisions relating to their own care.”
moderateGovernance: “governance systems continued to require improvement, as the provider and registered manager had not identified the areas of improvement we found during our inspection visit.”
minorGovernance: “The provider had failed to respond to CQC's requests for information in the form of the provider information return.”
Strengths
· Sufficient staff to support people safely with scheduled care calls; carers mostly arrived on time.
· Medicines were managed safely with regular monthly audits and competency observations.
· Staff received safeguarding training and knew how to recognise and report abuse.
· Staff completed the Care Certificate induction and received ongoing role-specific training (e.g. diabetes).
· Effective on-call system and regular supervisions/spot checks supported staff.
Quality-Statement breakdown (15)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood