Background to this inspection
Updated
12 January 2024
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
The inspection team consisted of an inspector, a medicines inspector, a regulatory co-ordinator and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Phoenix Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Phoenix Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post.
Notice of inspection
The inspection was unannounced. Inspection activity started on 22 November 2023 and ended on 12 December 2023. We visited the service on 22 and 30 November and 5 December 2023.
What we did before the inspection
We reviewed information we had received about the service since the provider registered. We sought feedback from the local authority quality and safeguarding teams who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spent time with people in the communal areas observing the care and support provided by staff. We spoke with 5 people who used the service and 3 relatives about their experience of the care provided. We spoke with 9 staff including the manager, peripatetic manager, area manager and support staff.
We reviewed a range of records. This included 4 people's care records and 5 people's medicine records. We looked at 3 staff recruitment files. A variety of records relating to the management of the service were reviewed.
We provided feedback to the manager and peripatetic manager when we visited on site on 5 December 2023 and at the end of the inspection.
Updated
12 January 2024
About the service
Phoenix Court is a residential care home providing personal care for up to 7 people with a learning disability and autistic people. At the time of our inspection there were 5 people using the service.
People’s experience of the service and what we found:
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Support:
Risks to people were not always identified, assessed or mitigated. Medicines were not always managed safely. Staffing arrangements need to be reviewed as although there were enough staff to keep people safe, additional duties impacted on the level of support staff could provide. Thorough recruitment processes were not always implemented. Quality assurance processes were not robust as some issues we found at inspection had not been identified or addressed. However, the provider acted promptly in taking action to address the issues and made improvements during the inspection. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right Care:
People were comfortable and relaxed around each other and in the company of staff. Staff knew people well and had developed positive relationships with individuals. The management team were in the process of updating support and care documentation. Some records contained person-centred information, but others lacked detail and did not accurately reflect people’s needs. Systems were in place to safeguard people from abuse.
Right Culture:
People were supported with social activities and accessing the community. Staff involved and encouraged people with daily living activities such as preparing and serving meals. People were supported to keep in touch with relatives and friends who could visit at any time.
A new manager started in post on the first day of the inspection. Apart from the manager, no senior staff were employed which meant staff roles were not clear in terms of who took responsibility and was in charge when the manager was off. The provider had an action plan in place to make improvements to the service and was working with external stakeholders to implement the changes.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good, published on 9 December 2020. There were no breaches of regulations, however, we made a recommendation in relation to medicines.
Why we inspected
This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘All inspection reports and timeline’ link for St Annes Community Services – Phoenix Court on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to regulations 12 and 17.
Please see the action we have told the provider to take at the end of this report.
Follow Up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.