16 May 2022
During a routine inspection
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.