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This inspection took place on 2 December 2025 to 14 January 2026 and was unannounced. Phoenix Healthcare is a domiciliary care agency providing personal care to people in their own home. The service was registered to provide support to older people, younger adults, people living with a diagnosis of dementia, people with substance misuse, people with a learning disability and people on the autistic spectrum and people with a physical disability. At the time of our inspection, people in receipt of a regulated activity were older people and younger adults. No service was provided to anyone with a learning disability or persons on the autistic spectrum. The provider was also registered to provide supported living due to the service not providing a regulated activity at the time of our inspection; supported living did not form part of this inspection. This inspection was carried out in response to serious concerns raised about the quality and safety of the service. During the inspection, we identified breaches of the legal regulations this was in relation to Good Governance and Safe Staffing. People did not always receive effective care and support. Although some care plans were person‑centred and initial assessments were completed, information was not consistently updated when people’s needs changed. Staffing instability and high use of agency staff meant people were not always supported by carers who knew them well, and communication across teams was inconsistent. Gaps in monitoring, handover and record‑keeping meant outcomes were not always reviewed or used to drive improvement. People were generally treated with kindness and respect by regular staff who knew them well and supported them with dignity. However, this was not consistent across the service. Experiences varied depending on which staff attended, and agency or unfamiliar carers did not always demonstrate the same understanding or person‑centred approach. People, relatives and staff told us communication was poor due to the absence of clear handovers, including uncertainty about which staff member would be attending each call, and staff not receiving regular supervision. Although regular staff promoted people’s independence and respected their preferences, inconsistencies in staffing, rushed care and poor communication meant people did not always experience compassionate or personalised support. The provider did not always ensure people received coordinated or person‑centred care. Although regular staff understood people’s preferences, care was inconsistent when agency or unfamiliar staff attended. Care plans contained personalised information, but gaps in reviews and updates meant changes were not always identified or acted on. Systems designed to support continuity, such as rotas, call monitoring and handovers, were unreliable, resulting in missed or late visits and relatives stepping in to provide care. Information was not always accessible in formats suited to people’s needs. People’s views were not consistently gathered or acted on, and lessons from complaints were not shared. Inconsistent staffing, poor communication and gaps in access and monitoring meant people did not always receive timely, reliable or equitable care. Leadership and governance were not effective, and the service did not have a clear vision, strategy or culture based on transparency or inclusion. Communication was poor, concerns were not acted on, and staff lacked clarity about their roles, expectations and priorities. Governance systems were weak or absent, meaning key risks such as missed visits, unsafe staffing, lack of DBS checks were not identified or addressed. Audits lacked analysis or follow‑up; concerns raised by people, relatives and staff were not always investigated; staff supervision was inconsistent; and staff were not always paid correctly or on time, contributing to low morale and unsafe practice. Leaders did not collaborate effectively with external partners, and repeated concerns about unsafe care were not investigated or used to drive improvement. Overall, significant failings in leadership and oversight meant the provider could not assure the delivery of safe, consistent or well‑managed care.
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