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Archived: Phoenix Surgery Good

The provider of this service changed - see new profile

Reports


Inspection carried out on 29 May to 29 May 2018

During a routine inspection

This practice is rated as Good overall. (Previous inspection 16 September 2015 – Requires Improvement).

The key questions are now rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection of Phoenix Surgery on 11 January 2017. Overall the practice was rated as requires improvement. The comprehensive report for the January 2017 inspection can be found by selecting the ‘all reports’ link for Phoenix Surgery on our website at www.cqc.org.uk.

Following the inspection on 11 January 2017, the provider sent us an action plan that set out the actions they would take to meet the breached regulations. We then carried out an announced follow-up comprehensive inspection at Phoenix Surgery on 29 May 2018, to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 11 January 2017.

This report covers the announced follow-up comprehensive inspection on 29 May 2018. We found the provider had made improvements since our inspection on 11 January 2017. The information we received enabled us to find the provider was meeting the regulations that it had previously breached for safe, effective and well-led services.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • The provider should continue to make efforts to increase the programme coverage of women eligible to be screened for cervical cancer.
  • The provider should review arrangements for registering patients with diabetes, and increasing awareness and uptake of childhood immunisation vaccinations, so that these indicators are comparable with key indicators.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection carried out on 11 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Phoenix Surgery on 11 January 2017. Overall the practice is rated as requires improvement.

The practice is run by Dr. Peter Swinyard since August 2016. Prior to this change the practice was under a partnership of which Dr. Peter Swinyard was a partner. Due to the change in legal entity the report only refers to information from August 2016 to 11 January 2017.

Our key findings across all the areas we inspected were as follows:

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However there were gaps in the training records which meant the practice could not demonstrate all mandatory training such as information governance, fire safety training and infection control training, had been undertaken.
  • The staff utilised secondary care resources to provide the most appropriate reviews and treatment plans, for example a local consultant advice line which covered a range of specialist services (including paediatric advice, neurology, rheumatoid conditions and gynaecology) and worked with the local diabetes consultant.

  • Although one clinical audit had been carried out, the practice did not demonstrate that audits were driving improvements to patient outcomes.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Although most risks to patients who used services were assessed, the systems and processes to address these risks were not demonstrated to have been implemented well enough to ensure patients were kept safe. For example although the practice had a number of policies and procedures to govern activity and manage risks, some were only written on the day before or during the inspection. For example the fire safety risk assessment and legionella risk assessment were written the day before the inspection (10 January 2017). (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

  • The arrangement for governance and performance management did not always operate effectively. A number of policies and processes were not embedded or established. There had not been any review of the governance arrangements or the information used to monitor or improve performance.

  • The practice sought feedback from staff and patients, including from questionnaires and text feedback, which it acted on. The practice had made a number of attempts to establish a patient participation group (PPG) but did not currently have an active PPG.

The areas where the provider must make improvements are:

  • Implement and monitor fire safety processes and fire safety checks.

  • Implement procedures for monitoring actions needed following medicines alerts.

  • Ensure training records are completed and mandatory training is undertaken.

  • Ensure the governance processes are in place to monitor risks to patients and that the practice has sufficient capacity to monitor these areas.

  • Ensure policies and procedures are accessible to staff and are applied.

In addition the provider should:

  • Carry out clinical audits and re-audits to improve patient outcomes.

  • Continue to work towards gaining patient feedback.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice