Background to this inspection
Updated
21 July 2022
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.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
One Inspector and a member of the CQC medicines team were on site and an Expert by Experience making phone calls off site carried out the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. An internal specialist advisor for people who are Deaf and British Sign Language user was consulted throughout the inspection.
Service and service type
Ashley Phoenix 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. Ashley Phoenix is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service since the last the home registered and since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to submit a completed Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We did review it once it came in during the inspection. We used all this information to plan our inspection.
During the inspection
We were unable to speak with people who used the service because of their limited verbal communication. Instead we completed a wide range of observations including using the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We spoke with five relatives about their experience of the care provided on the telephone. We also spoke with seven members of staff including the registered manager, deputy manager and a representative of the provider. We reviewed a range of records. This included five people’s care records and three medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
21 July 2022
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 assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
About the service
Ashley Phoenix is a residential care home providing personal care to seven people who were registered deafblind with additional complex needs. The service can support up to nine people. Eleven months ago, the provider changed for this service. The home is situated in a specialist complex for people who are deaf and/or deafblind.
People’s experience of using this service and what we found
Right Support
People were not always supported by staff who had training in supporting and communicating with those who were deafblind. Systems had not always identified or acted promptly to ensure the environment was safe. Staff were not always making referrals to health professionals in a timely manner. Staff had training to support people with their medicines and knew their preferences for administration. However, some improvements were required. People were living in an environment that was personalised and adapted to meet their needs.
Staff knew people well and how to recognise changes including calming them when they were upset or distressed. Staff supported people to take part in activities and pursue their interests in their local area.
Right Care
Staff promoted equality and diversity in their support for people. However, no recent attempts had been made to respect people’s cultural needs as Deafblind individuals and provided opportunities to access the Deaf community. People’s care and support plans were not always reflecting their range of needs and capturing the knowledge staff had. Staff assessed risks people might face. Although at times these lacked details and knowledge experienced staff held. Where appropriate, staff encouraged and enabled people to take positive risks.
People received kind and compassionate care from staff who knew them very well. Staff protected and respected people’s privacy and dignity most of the time. They understood and responded to their individual needs. People could take part in activities and pursue interests that were tailored to them. The service gave people opportunities to try new activities that enhanced and enriched their lives.
Right culture
People were not always supported by staff who helped them build links with the Deaf and blind communities. Systems were not effective to manage the quality and safety of support for people. Staff turnover was very low, which supported people to receive consistent care from staff who knew them well although care plans did not always reflect staff knowledge. Systems were not fully in place to ensure people lived in an open and transparent culture that learnt from mistakes.
Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. People and those important to them, including advocates, were involved in planning their care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 30 June 2021 and this is the first inspection.
The last rating for the service under the previous provider was good, published on 21 February 2019.
Why we inspected
The inspection was prompted in part due to concerns received about decisions for people who lacked capacity or who had fluctuating capacity. Also, a lack of notifications on our system for a service of this type. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to safe care and treatment, keeping people safe from potential abuse, person centred care and leadership and governance at this inspection. Please see the action we have told the provider to take at the end of this report.
We have also made recommendations around recruitment of new staff and decision making for people who lack capacity.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.