The Care Quality Commission (CQC) has rated The Phoenix, in Lincoln, inadequate and placed it in special measures following an inspection in August.
The inspection was prompted in part due to concerns received about allegations of abuse, staffing and poor management culture.
The Phoenix is a residential care home, ran by Linkage Community Trust, that provides personal care to up to six people. The service provides support to people living with learning disabilities and autistic people.
This inspection looked at the areas of safe, effective and well-led only. Following this inspection, the care home’s overall rating has dropped from good to inadequate and the service has been placed in special measures. The service was also rated inadequate for being safe and well-led and rated requires improvement for effective.
Debbie Ivanova, CQC’s director for people with learning disabilities and autistic people, said:
“When we inspected The Phoenix, we found a service where the standard of care had deteriorated significantly since our last inspection. People’s safety and wellbeing needs weren’t always being met, and risks weren’t effectively managed.
“It was concerning that people at the service didn’t always feel safe. There were times when people experienced distress and incident records showed that they had retreated to their bedrooms as they were scared.
“Two people at the service had complex needs, one person's needs were medical, and the other needed support when they became distressed. With only one member of staff available during the night there was a risk that they wouldn’t able to meet the needs of each person which placed them at risk of harm.
“People's views or need for someone to advocate for them were not always considered prior to decisions being made about them. For example, we saw on inspection that managers hadn’t followed the principles of the Mental Capacity Act, or involved family and key workers, when making decisions about a person.
“We will continue to monitor The Phoenix closely to ensure people are safe. If we are not assured people are receiving safe care, we will not hesitate to take action.”
Inspectors found:
- Risks associated with service users care and support were not always identified, assessed or mitigated
- Medicines records did not always contain all the necessary information required for safe practices
- Cleaning records we reviewed were not always completed and areas of the home looked visibly dirty
- Accidents and incidents were not always recorded effectively at the service
- Managers had not identified that some people living at the service required a DoLS authorisation to be in place. This placed people at risk of being unlawfully deprived of their liberty
- People's views or need for someone to advocate for them was not always considered prior to the management team progressing with decisions about the person.
However:
- People were supported and encouraged to access the community; going to local parks and shops as well as a day centre run by the organisation
- Staff worked with other agencies to provide consistent, effective and timely care
- Staff had been working with a specialist in managing and supporting people who showed signs of distress
- Staff supported people to make independent choices about their food. Where possible people were encouraged to be involved in the preparation of their meals
- The senior management team said they were working on how to better involve and gain the views of people at the service
- Staff told us they felt their induction period was very well organised, giving them enough skills and knowledge to start supporting people.