Phoenix Park Care Village is purpose built and is situated on the outskirts of Scunthorpe. The home provides care and accommodation for up to 146 people. There are three units, Hilltop, Overfields and Fairways.

Hilltop predominately provides care for older people. Some people have nursing, dementia, mental health or challenging behaviour needs. The ground floor accommodates a mixture of people some with nursing needs. The first floor accommodates people who all have nursing needs. There were 59 people living in the Hilltop unit at the time of our visit.

Overfields predominately provides care for younger adults who have complex care needs relating to their mental health. There were 34 people living on this unit at the time of our visit.

Fairways is a 35 bedded unit. Mainly for men with mental health needs and challenging behaviour needs. This unit opened on 17 July 2018. There were 13 people living on this unit. Altogether there were 106 people living at the service at the time of the inspection.

Phoenix Park Care Village is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

There were two registered managers’ in post due to the size of the service. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Minor issues were found on the first day of the inspection. These were regarding medicines ‘as required' protocols that required reviewing or implementing for eight people and there were minor issues with unsecured gloves and cleaning fluid found in two areas. These issues were corrected immediately by the management team. Staff were provided with supervision and further training during the inspection to make sure these minor issues would not re-occur. We found no further concerns in these areas over the next two days of the inspection.

People were protected from harm and abuse. Staff knew how to recognise and report potential issues. Safeguarding issues were reported and acted upon. Incidents and accidents were monitored and investigated. Risks to people’s wellbeing were assessed, monitored and addressed to maintain people’s health and safety. Staff were aware of how to support people if they displayed challenging behaviour.

There were enough skilled and experienced staff to meet people's needs. Staff undertook training in a variety of subjects had supervision and an annual appraisal to maintain and develop their skills.

People had maximum choice and control over their lives. Staff supported people in the least restrictive way. Policies supported this practice. People were involved in making decisions about their care and support.

People’s dietary needs were assessed and monitored to ensure their dietary needs were met.

Staff provided people with caring, kind and compassionate care and support. Staff provided appropriate reassurance and support if people became anxious, upset or displayed challenging behaviour. People’s privacy and dignity was protected. Information was provided to people in a format that met their needs, in line with the Accessible Information Standards.

An assessment of people’s needs took place. People were not accepte

Phoenix Park Care Village is a purpose build home situated on the outskirts of Scunthorpe. It is registered to provide accommodation for people who require nursing or personal care for a maximum of 111 people.

The service is comprised of two units known as Hilltop and Overfields. Hilltop offers 77 single, en-suite rooms for older people some of whom may be living with dementia, complex health conditions requiring nursing care and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs and mental health conditions. The service offers a number of communal lounges, conservatories, kitchens, a mixture of dining and bistro areas, games rooms, a hairdressing and beauty salon, secure gardens and outdoor seating areas.

At the time of this comprehensive inspection, there were two registered managers in post. The registered provider had made one registered manager responsible for Hilltop and the other responsible for Overfields. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out this unannounced comprehensive inspection of the service on 16 and 19 December 2016 to check that the registered provider was now meeting legal requirements and had achieved compliance with the regulations following breaches identified at the inspections on 17, 25 & 28 September 2015, 27 & 28 January and 12 February 2016 and 1, 2 and 8 September 2016.

At the aforementioned inspections the registered provider was non-compliant with regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant the registered provider was not meeting the requirements of regulations pertaining to providing person centred care, providing safe care and treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and experience to meet people's needs.

During this inspection we saw improvements had been made throughout the service and appropriate action had been taken to ensure compliance with the regulations.

People who used the service received person centred care. Care plans contained accurate descriptions of the current care needs and detailed guidance to enable staff to deliver care and support in line with their preferences.

People received safe care and treatment in a clean and hygienic environment. Staff wore personal protective equipment when required and worked in line with best practice guidance to ensure appropriate standards of infection prevention and control were adhered to. The environment was clean and free from unpleasant odours.

The registered provider’s governance systems had been reviewed and developed to ensure their effectiveness. Quality assurance tools such as audits, checks, questionnaires and observations were undertaken to highlight shortfalls in care and support and to drive the continual improvement of the service.

Staff had completed relevant training to equip them with the skills and abilities to deliver care safely and effectively in a number of subjects including safeguarding of vulnerable adults, The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, fire awareness, first aid, dignity in care, dementia and mental health awareness.

People who used the service were protected from abuse and avoidable harm. Staff were aware of their responsibilities to report signs of potential abuse and poor care. Known risks were identified and mitigated. Plans were in place to deal with foreseeable emergencies. Staff were recruited following appropriate checks and any gaps in their work history were explored. People’s medicines were stored, ordered

Phoenix Park Care Village is a purpose build home situated on the outskirts of Scunthorpe. It is registered to provide accommodation for people who require nursing or personal care for a maximum of 111 people.

The service is separated into two units, Hilltop and Overfields. Hilltop offers 77 single, en-suite rooms for older people some of whom may be living with dementia, complex health conditions requiring nursing care and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs and mental health conditions. The service offers a number of communal lounges, conservatories, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.

At the time of this comprehensive inspection, there was no registered manager in post. Two managers who worked at the service had applied to become registered and completed their ‘fit persons’ interview with a Care Quality Commission (CQC) registration inspector but the application process was still in progress. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out this unannounced comprehensive inspection of the service on 1, 2 and 8 September 2016 to check that the registered provider was now meeting legal requirements and had achieved compliance with the regulations identified in breach at the comprehensive inspection on 17, 25 & 28 September 2015 and the focused inspection on 27 & 28 January and 12 February 2016.

At the comprehensive inspection of the service on 17, 25 & 28 September 2015, we found the registered provider was non-compliant with regulations 9, 10, 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant the registered provider was not meeting the requirements of regulations pertaining to providing person centred care, treating people with dignity and respect, obtaining appropriate consent and following the principles of the Mental Capacity Act 2005, providing safe care and treatment, safeguarding people from abuse and improper treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and support to meet people's needs.

At the focused inspection on 27 & 28 January and 12 February 2016 we found the registered provider had failed to take appropriate action to achieve compliance with any of the regulations identified during the previous inspection in September 2015. We also found evidence that the registered provider was in breach of regulation 19. This meant the registered provider was not meeting the requirements of regulations pertaining to employing fit and proper persons.

After the focused inspection on 27 & 28 January and 12 February 2016 the registered provider contracted the support of a management company to help them make the required improvements and ensure they achieved compliance with the regulations.

At the previous inspections of the service, we found that people did not always receive person-centred care. During this comprehensive inspection we found that some people’s care plans were up to date, reflected their current care and support needs and provided appropriate guidance to enable staff to support people effectively. However, some care plans contained contradictory information, did not reflect people's current care and support needs or contain adequate guidance to ensure they were supported consistently and in line with their preferences.

We also found that there was more than one format or style of care plan in use at the service, which meant staff may have found it difficult to find inform

Phoenix Park Care Village is a purpose build home situated on the outskirts of Scunthorpe. It is registered to provide accommodation for people who require nursing or personal care for a maximum of 111 people.

The service is separated into two units Hilltop and Overfields. Hilltop offers 77 single ensuite rooms for older people some of whom may be living with dementia, complex medical conditions and behaviours that may challenge the service and others. Overfields provides 34 single ensuite rooms for younger adults with complex needs and mental health conditions. At the time of our inspection there were 12 vacancies within the service. The service offers a number of communal lounges, conservatory, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.

At the commencement of our inspection there was a registered manager in post. A registered

manager is a person who has registered with the Care Quality Commission [CQC] to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. By the third day of our inspection the registered provider had decided it would be prudent to move the registered manager to run another registered service.

We carried out an unannounced comprehensive inspection of this service on 17, 25 & 28 September 2015. During the inspection we found the registered provider was in breach of Regulations 9, 10, 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant that the registered provider was not meeting the regulations relating to providing person centred care, treating people with dignity and respect, obtaining appropriate consent and following the principles of the Mental Capacity Act 2005, providing safe care and treatment, safeguarding people from abuse and improper treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and support to meet people’s needs.

The registered provider gave us their assurance that further admissions to the service would not take place until we were satisfied appropriate arrangements were in place to ensure people’s health, safety and welfare was protected and the registered provider had achieved compliance with all of the relevant regulations.

We undertook this focused inspection on 27 & 28 January and 12 February 2016 to check whether the registered provider was now meeting legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Phoenix Park Care Village on our website at www.cqc.org.uk.

This inspection was completed because the registered provider’s nominated individual told us, ‘all of our internal governance measures have evidenced a positive service to the clients, and we are confident that a return inspection will show significant improvement to the ratings previously offered’ and ‘I am confident that the service being offered is both safe and effective, and is able to evidence a sustained level of good practice and outcomes for clients’. The nominated individual suggested a phased lift to the voluntary suspension of new admissions so we inspected to ascertain whether compliance had been achieved.

At our comprehensive inspection of the service in September 2015 we found that people did not always receive person-centred care. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 9. People’s care plans were no

We conducted this review as we had received concerns about the quality of meals, management of one to one care and the cleanliness of the building.

Although the majority of people were unable to communicate with us due to their complex physical or mental health needs we spoke with nine people who used the service and observed practice to gain information about peoples experiences of the service provided.

We found people were supported to be able to eat and drink sufficient amounts to meet their needs and that they were provided with a choice of suitable and nutritious food and drink. People who used the service told us that they enjoyed the meals provided. Comments included "The food is very good" and "The food is fantastic." People told us they had a choice at meal times and one person said "We have different choices every day, we don't have the same thing twice in a week." We observed staff were patient and supportive when assisting people with their meals.

We found that one to one support was well managed and that there was sufficient staff to support people.

We found that there were good standards of cleanliness and that this had continued to improve since our last inspection. People who used the service told us that they were satisfied with the cleanliness of the home and told us their room was cleaned every day. Comments included "The home is kept marvellous" and "The home is kept clean and tidy."

We found that people received the care they needed to meet their needs. We found that the majority of people who used the service had very complex needs and were unable to comment in any detail however they told us they were happy. Visitors told us that their relative's were very well cared for.

We found that that the environment was clean and tidy and systems were in place to ensure that this could be maintained. We found significant improvement to the standards of cleanliness in Overfields dining and kitchen areas and in food hygiene practice. People we spoke with told us that their rooms were cleaned on a daily basis and one person commented “I can have my room and bed cleaned more than once a day, I just need to ask and staff will do it."

All of the people who lived in the area of the home we inspected had complex needs related to their mental health. This limited their ability to communicate with us however people told us they were happy living in the home and felt they were well cared for. Comments included “I am happy here” and “I am happy living in the home, they come and help me.”

People told us they were satisfied with the cleanliness of the home. One person told us “They come in everyday to clean my room.”

People told us they liked the staff and their needs were met. Comments included “The staff are very good” and “There is always someone around.”

People who live in the home had a variety of complex needs and some people had difficulty expressing their opinions about the service and whether their needs were met. However where people were able to speak with us they told us that the food served in the home was of a good standard. They told us that they had a choice at meal times and that they had sufficient to eat and drink. Comments included, “I am asked what I would like everyday and there is always a choice,” “You don’t go hungry, you get snacks between meals and you can have sandwiches all day if you want,” “They ask you if you want anything else” and “You can have drinks whenever you want.”

People who live in the home have a variety of complex needs and some people had

difficulty expressing their opinions about the service and whether their care needs were

met. However we spoke to a number of people who told us they were well looked after and happy living in the home. Comments included “I am well looked after.”

People using the service confirmed that they liked the food provided. One person confirmed they had had their dinner and when asked if they had enjoyed it answered “Yes.”

We spoke with a relative who visited the home daily. They stated staff attended frequently to their relative. They told us carers are lovely and they communicate any changes relating to their relatives health and wellbeing. They told us they were “Very satisfied with the care.”

People who live in the home have a variety of complex needs and some people had difficulty expressing their opinions about the service and whether their care needs were met. However we spoke to a number of people who told us they were happy living in the home and they described how they were able to make choices about their daily routines and how their care is delivered.

Comments included "It is fantastic, I was able to bring in my own things, I couldn’t have picked better", "They let me lead my life", "I don’t like mixing with the others so I stay in my room, the staff brought me a bird table to watch outside my window and the manager gave me some interesting proposals for getting out more", "I can say if I want a male or female carer but it doesn’t bother me", "I have my hair done every week" and "I was given a choice of bedroom".

There were some comments which may indicate that some staff do not always accommodate people’s individual choices or promote privacy and dignity. Comments included "I wake up early and most carers assist me then fetch me a cup of tea but others say the kitchen isn’t open yet so I cant have a cup of tea", "Most protect my privacy but some just walk straight in" and "Some times I feel rushed with the younger carers".

We received positive comments about the staff group which included ‘staff are good’, ‘carers are very good’, ‘yes there are enough staff, they are always there to help you, they have time for people’ and ‘I have nothing but praise for the manager’.

However there were some comments which may indicate that there are times when there is not sufficient staff on duty. Comments included ‘sometimes I have to wait for pain relief but it depends who is on’, ‘sometimes I have to wait as they are short staffed, staff say they are short staffed’, ‘sometimes you have to wait for the bell to be answered and there’s no chance at meal times or change over' and ‘bells are a nightmare, they don’t come quick to answer the bells’.

Phoenix Park Care Village is a purpose build home situated on the outskirts of Scunthorpe. It is registered to provide accommodation for people who require nursing or personal care for a maximum of 111 people.

The service is separated into two units Hilltop and Overfields. Hilltop offers 77 single en-suite rooms for older people some of whom may be living with dementia, complex medical conditions and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs, disabilities and mental health conditions. At the time of our inspection there were 109 people living at the service. The service offers a number of communal lounges, conservatory, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.

The inspection took place over three days on 17, 25 and 28 September 2015. This was an unannounced inspection which meant that staff and the registered provider did not know that we would be visiting. At the last inspection in June 2014 we found the registered provider was compliant with all the standards we assessed.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission [CQC] to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We brought the inspection forward due to the number of incident notifications we had received from the service. We also had a number of concerns raised by relatives of people living at the service, which included concerns regarding the cleaning standards and poor standards of care. A local Member of Parliament [MP] and two of their constituents had also raised concerns about the care practices taking place at the service. There was also one on-going investigation into allegations of abuse which relates to an ex-employee at the service. This continues to be investigated by Humberside police.

We found the information submitted to the CQC and local safeguarding teams was not always accurate and lacked the detail needed to understand fully what the concern had been. Therefore, we found it difficult to determine if further investigations were required; if the concerns should be escalated to other agencies or if the registered provider had taken the appropriate steps to mitigate any risks. Other agencies also reported to us that they had experienced difficulties accessing information from the registered manager when requested. Although staff told us they felt well supported we found that the governance systems in place at the service were not as effective as they could have been and we struggled to obtain information from the registered manager during our inspection.

We found that a number of people regularly displayed behaviours which challenged the service and others, which had led to physical interventions such as hand holds being used by staff. We found not all staff involved in these types of incidents had received appropriate physical intervention training.

For those who had received physical intervention training we found this was not accredited as recommended by the department of health and it did not assist staff to safely support someone using physical interventions; record what actions staff needed to take; the holds to be used for each person; or inform them that they needed to maintain very detailed information about how they had dealt with incidents.

We saw safety gates were widely used throughout the service. Staff explained that these were in place to prevent some people with behaviours that challenged accessing the individual bedrooms of people who lived in the home. We requested evidence to ensure this risk had been assessed, but the registered manager could not produce any risk assessment documentation to support these actions. We found no evidence to show that staff had taken any action to determine if alternative, less restrictive methods had been explored.

We found the home admitted people with a wide range of complex needs and conditions; many of which were related to a mental disorder. However, staff had not received training in supporting people with specialist conditions such as mental health disorders and Asperger. We also found that there were 58 people who had been assessed as requiring nursing care at the location. Of the qualified nurses employed at the service only one was a registered mental health nurse and none of the nurses were based in the Overfields unit. Thus we found that there was an over-reliance on care staff to provide the care and that these staff had not received the training needed to deliver these expectations.

Safe staff recruitment processes were not always followed. We saw one person had been employed even though they had received a serious warning from the police authorities on their Disclosure and barring service [DBS] check and one of the references stated they would not employ this person. We found that the registered provider had not completed a risk assessment for this person around the disclosure and had not taken any additional steps to ensure the person was fit to work at the home and with vulnerable people.

The Mental Capacity Act [MCA] 2005 was not fully understood by all staff members and there was also a limited understanding of the MCA Deprivation of Liberty Safeguards [DoLS] and what restriction, if any could be implemented within practice. We saw that 11 safety gates were being widely used throughout the Hilltop unit but we did not see MCA documentation to evidence this as in the best interests of people and the least restrictive option that could be identified.

People who used the service and their relatives told us there was a good range of food available which looked well-presented and appetising. We saw positive interactions between some people and staff and people told us the staff were caring. However, we also saw there was a lack of meaningful activities taking place in the Hilltop unit and many people appeared to be sleeping for most parts of the day. A number of people were supported by staff on a one to one basis but we saw very little communication and interactions between those people and staff members in these situations on the Hilltop unit.

People’s dignity was not always respected on the Hilltop unit. We saw people being left in positions which compromised their dignity. Effective and safe standards of hygiene had not been maintained in all areas of the service.

The storage and administration of medicines were safe and well managed along with thorough maintenance checks that ensured equipment was safe and fit for purpose.

We found multiple breaches of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. We are considering our enforcement actions in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded. You can see what action we told the registered providers to take at the back of the full version of the report.