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CQC report explained · a residential care home, run by Linkage Community Trust

The Phoenix

St. Helens Avenue, Lincoln, LN6 7RA

Goodpublished 16 November 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found that risks such as choking, road safety and financial abuse had been identified and managed. Medicines, infection control, staffing and recruitment were also found to be safe.
Effective?
Good
The home was working within the principles of the Mental Capacity Act, and appropriate authorisations had been sought where needed. Staff training, healthcare support, food choices and people's individual needs were appropriately addressed.
Caring?
Good
This key question was not inspected during this focused visit. The previous rating was carried forward.
Responsive?
Good
This key question was not inspected during this focused visit. The previous rating was carried forward.
Well-led?
Good
Inspectors found effective audits, incident monitoring and leadership oversight. People, relatives and staff had opportunities to give feedback and contribute to improvements.
The latest report, explained

What inspectors found, November 2023

Rated Good; inspectors found safer, more person-centred care after the home improved from Inadequate and left Special Measures.

This was an unannounced focused inspection on 14 September 2023. One inspector spoke with people, relatives, staff and managers, observed care, and checked care, medicine, recruitment, training and management records.

The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks were assessed, medicines were managed safely, staffing had improved, and people received personalised support. Staff understood safeguarding, consent and people's communication needs.

The previous inspection had rated the home Inadequate and found breaches of regulations. Inspectors found enough improvement at this visit, so the home was no longer in breach and was no longer in Special Measures.

This was a focused inspection. Caring and Responsive were not inspected at this visit, so their previous ratings were used when calculating the overall Good rating.

What inspectors praised

  • Risk management

    Risks linked to people's needs had been identified and reduced. Staff knew how to recognise and report possible abuse.

    “Risks associated with people's needs had been identified, assessed and mitigated.” from the report

  • Medicines

    Medicines were managed safely, including controlled medicines and medicines given when needed. Staff followed people's preferred ways of communicating pain.

    “Medicines were managed safely and in line with current guidance.” from the report

  • Staffing improved

    The provider had increased night staffing since the previous inspection. Inspectors found enough staff during the day to meet people's needs.

    “Since the last inspection the provider had increased the number of staff working at night.” from the report

  • Person-centred support

    Support plans reflected people's views and wishes. People were involved in daily choices, food preparation, community activities and planning their support.

    “Support plans were person-centred and reflected people's views and wishes.” from the report

  • Stronger oversight

    The home had regular audits and reviewed incidents to identify lessons and reduce future risks. Senior leaders supported the manager to make improvements.

    “Governance systems had been effective in identifying and addressing shortfalls within the service.” from the report
What inspectors were concerned about

  • Environmental work was still ongoing

    minor

    An action plan to improve the environment was still in place. Some communal areas had been redecorated, while other work was still in progress.

    “We saw redecoration of communal areas had taken place or was in progress” from the report
Questions to ask them, based on this report
  1. 01How do you check that the increased night staffing continues to meet each person's needs?
  2. 02What work remains from the environmental action plan, and when will it be completed?
  3. 03How are people's individual communication methods used when they may be in pain or need medicine?
  4. 04How do you monitor whether the improvements made since the previous inspection are being maintained?
  5. 05What was the previous rating for Caring and Responsive, and what evidence can you show about these areas now?

This was a focused inspection of Safe, Effective and Well-led, with infection prevention and control also considered; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 16 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, September 2023

Rated Inadequate and placed in special measures; inspectors found serious safety, staffing and management failures.

This was an unannounced focused inspection on 16 and 18 August 2022. The inspector spoke with one person, three relatives and six staff, and reviewed care records, medicines records, staff files and management records.

The home was rated Inadequate overall. Safe and well-led were rated Inadequate, while Effective was rated Requires Improvement. Inspectors found unsafe medicines management, missing or incomplete risk information, not enough night staff, poor incident recording and weak checks by managers.

People were not always supported in line with the Mental Capacity Act. Some Deprivation of Liberty Safeguards applications had not been made. Inspectors also saw kind interactions, support to use the community and staff who understood people's nutritional needs.

What inspectors praised

  • Kind interactions

    Inspectors saw staff interacting kindly with people during the visit.

    “We observed staff interacting with people in a kind and caring manor.” from the report

  • Community access

    Staff supported people to go to local parks, shops and a day centre. Inspectors saw positive engagement while people came and went from the home.

    “Staff supported and encouraged people to access the community, going to local parks and shops as well as a day centre run by the organisation.” from the report

  • Staff training

    Staff had received relevant training and told inspectors that their induction gave them useful skills and knowledge.

    “Staff had received the relevant training or refresher training in order to meet the needs of the people at the service.” from the report

  • Safe recruitment

    Inspectors found that recruitment processes were in place.

    “There were safe recruitment processes in place at the service.” from the report
What inspectors were concerned about

  • Unsafe medicines management

    serious

    Medicine records did not always explain how medicines should be given. Required second signatures were often missing, creating a risk that errors would not be noticed.

    “Medicines were not managed safely at the service.” from the report

  • Risks not managed

    serious

    Risk assessments and care records were not always complete or current. One person left the home unsupervised, and not all doors were alarmed.

    “Risks associated with service users care and support were not always identified, assessed or mitigated.” from the report

  • Too few night staff

    serious

    Only one staff member worked at night, despite people having complex and changing needs. Inspectors said this created a risk that people's needs could not be met safely.

    “There were not always enough staff deployed at night to ensure risk assessments and management plans could be followed.” from the report

  • Mental Capacity Act failures

    serious

    The management team did not always identify when Deprivation of Liberty Safeguards were needed. Decisions were also made without consistently involving families, advocates or key workers.

    “People were not always supported within the principals of the mental capacity act this is a breach of Regulation 11” from the report

  • Weak management checks

    serious

    Audits and care plan reviews failed to identify important problems. Known high-risk issues were not acted on promptly.

    “The provider's failure to effectively monitor the quality and safety of the service was a breach of Regulation 17” from the report

  • Poor cleanliness and maintenance

    needs fixing

    Some areas were visibly dirty, cleaning records were incomplete and damaged decking could not be used safely. Staff did not always follow mask guidance.

    “Cleaning records we reviewed were not always completed and areas of the home looked visibly dirty.” from the report
Questions to ask them, based on this report
  1. 01How many staff now work on each night shift, and how are complex medical and distress-related needs covered?
  2. 02How are medicines given through a PEG recorded, checked and signed by the required staff?
  3. 03Which people's risk assessments and care plans have been updated since the inspection, and how often are they reviewed?
  4. 04Which people currently have a valid Deprivation of Liberty Safeguards authorisation, and how are families and advocates involved in decisions?
  5. 05What changes have been made to incident reporting and management audits, and can the home show evidence that these changes are working?

This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were carried over from the previous inspection. This explanation was written from the published report of 30 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of The Phoenix

3 rated inspections over 4 years: the service has held its Good rating throughout.

  1. November 2023Goodcurrent ratingup from Inadequate
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at The Phoenix →

  2. September 2023Inadequatedown from Good
    Safe: InadequateEffective: Requires improvementWell-led: Inadequate

    Read what inspectors found at The Phoenix →

  3. January 2020Good
    Safe: GoodEffective: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. November 2018

    Registered with the Care Quality Commission on 14 November 2018.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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