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Inspection Summary

Overall summary & rating


Updated 7 May 2019

This service is rated as Good overall.

The service had been previously inspected in February 2014. At this time services were not rated.

The key questions are 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 at The White Rose Surgery as part of our inspection programme.

The service delivers a range of health and care services including day care, diagnostic services and outpatient clinics and procedures for patient who access the service via an NHS referral.

One of the Directors of Phoenix Health Solutions Limited is the registered manager. A registered manager is a person who is registered with the Care Quality Commission 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.

The service made use of patient feedback as a measure to improve services. They had produced their own surveys and used the NHS Friends and Family Test, and results were analysed on a regular basis. Results obtained from the NHS Friends and Family Test in March 2019 showed that 100% of patients would be extremely likely or likely to recommend the service to others.

We also received 20 Care Quality Commission comment cards. These were all very positive regarding the care delivered by the service, many mentioning the caring and helpful attitude of staff.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines, and supported this work with clinical audits and the analysis of outcomes and performance.
  • 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:

  • Review and improve procedures for the date checking of emergency medicines and equipment.
  • Review and improve procedures to give greater assurance that consultants had received appropriate annual mandatory training.
  • Continue to follow up on actions identified in the last Infection Prevention and Contol Audit.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 7 May 2019

We rated safe as Good because:

Safety systems and processes

The service had systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff and which were communicated to service providers on induction. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard vulnerable adults from abuse. The service had appointed a safeguarding lead. It was noted that the service had not fully assured itself that all contracted clinical staff had completed all mandatory training such as safeguarding. Since the inspection we have been sent information by the service outlining a new procedure to ensure that contracted clinical staff have received mandatory training. In addition, the service has confirmed that they have been sent evidence and given assurance by such staff that this training has been completed.
  • The service had procedures in place which set out how they would work with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All directly employed, salaried staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.

  • There was a system in place to manage infection prevention and control (IPC). We saw that controls were in place to manage legionella (a bacterium which can be harmful to humans), and that an externally delivered IPC audit had been carried out in November 2018. However, it was noted that this audit had highlighted some issues. Whilst one issue in relation to sharps bins had been rectified immediately we were informed that a second issue in relation to a sink was to be held over until the next planned refurbishment of the building. Notwithstanding this point, the overall IPC audit compliance was 98% for the endoscopy suite and 100% for the theatre.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. The service had developed a comprehensive competency assessment to ensure staff allocated to deliver services were appropriately experienced and trained.
  • There was an effective induction system for staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities involved in the delivery of these NHS services.
  • Staff personnel files were comprehensive and contained information such as an assessment of immunity status.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The service used voice recognition software to manage discharge letters. This ensured that these were sent promptly.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they ceased trading.
  • Clinicians submitted appropriate and timely requests for sample tests in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service did not have a fully reliable system for the appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, and general equipment minimised risks. However, we found that some emergency medicines and equipment for use within the service had exceeded their date of use. These were immediately withdrawn, and products within date made available for use. It was also noted that checks on emergency medicines and equipment had not been carried out on a regular basis. Since the inspection the service has sent us details of a new weekly checking procedure which has been implemented within the organisation.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. For example, the service had identified that samples awaiting submission for further testing had been lost. They had taken the appropriate action which included contacting and recalling patients, and had analysed possible causes and solutions to prevent recurrence. In this instance the service had revised the standard operating procedure for sample storage and had introduced new storage and transport containers.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents.
  • When there were unexpected or unintended safety incidents, the service gave affected people reasonable support, truthful information and a verbal and written apology.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had a mechanism in place to disseminate information, learning and alerts to all members of the team using the clinical IT system, email and when relevant at meetings.



Updated 7 May 2019

We rated effective as



Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, and standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • The service had developed detailed specifications, pathways and standards for the delivery of specific procedures such as cataracts and gastroenterology. These set out clear practices to be put in place to ensure effective services.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients; this included continuity of care and the delivery of outpatient services.
  • Staff assessed and managed patients’ pain where appropriate.
  • The service had fitted out the premises to meet exacting local and national specifications. For example, the audiology suite incorporated an audiology booth and specialist diagnostic testing equipment.
  • The service prioritised patients with certain medical conditions such as diabetes for appointment times to ensure that they were not kept waiting for excessive periods.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. This included:

    • The use of clinical audits. The service had developed and carried out a number of both single cycle and two cycle clinical audits to assess performance. For example, an audit carried out in relation to cataract surgery showed improved compliance between the first and second audit cycle against internal targets.
    • In addition to clinical outcomes the service assessed the impact of procedures via Patient Reported Outcome Measures (PROMs).These assessed the quality of care delivered to NHS patients from the patient’s perspective.

  • We saw that audits and other quality improvement activity were discussed at in-house Audit and Governance Group meetings.
  • The endoscopy service had been accredited (2016-2021) by the Joint Advisory Groups of the Royal College of Physicians.
  • The service had agreed quality improvement goals with the local Clinical Commissioning Group. We saw that in 2017/18 the service had met all these set goals.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. Induction records were detailed and covered assessments of competency. The service had developed a comprehensive competency assessment to ensure staff allocated to deliver services were appropriately experienced and trained.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council (NMC) and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • We discussed with the service the need to ensure that they had adequate assurance that contracted service providers had completed the required mandatory training in respect of subject areas such as safeguarding. Since the inspection the service has introduced a new procedure which gave assurance that such staff had received the required mandatory training.

Coordinating patient care and information sharing

Staff worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, letters were sent to referring GPs within 24 hours of the procedure. This included details of any newly prescribed medication or changes to medication.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. The service had developed specifications, pathways and standards for the delivery of specific procedures and these contained details of necessary pre-checks/test results.
  • As all patients were referred into the service by the NHS all required information was shared with the referring GP. For example, details of their consultation and any medicines prescribed on each occasion they used the service.
  • The provider had risk assessed the treatments they offered, and ensured known risks were discussed with patients before treatment was commenced.
  • The provider had processes in place to ensure care and treatment for patients in vulnerable circumstances were coordinated with other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.



Updated 7 May 2019

We rated caring as



Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. For example, many comment cards we received noted the helpful and caring attitude of staff.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • The reception desk was low level and was suitable for patients who were wheelchair users to easily book in on arrival.
  • We saw in-house patient survey data which indicated high levels of patient satisfaction with services. For example, in the 2017/18 cataract/ophthalmic services survey all 167 respondents stated that they felt listened to and had been treated with dignity and respect.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. Information leaflets could be made available in easy read formats or other languages, to help patients be involved in decisions about their care. In addition, a hearing loop was available for patients who had a hearing impairment.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • We were informed by the provider that for patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • There were separate areas for male and female patients for endoscopy.
  • Breast feeding arrangements were in place within the premises.



Updated 7 May 2019

We rated responsive as



Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, home visits were available for adult hearing tests.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. This included making adaptations and fitting additional equipment such as fitting a low access desk at reception.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The service communicated in a timely way with referring GPs; usually within 24 hours of the patient receiving treatment.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. We discussed with the provider a detailed complaint they had dealt with concerning a patient who had received a second opinion which was at odds with the information they had received from the service’s own consultant. We saw that the complaint had been investigated and analysed and that actions had been put in place to resolve the situation.
  • It was noted that in all cases, complaint correspondence did not include the full address of the Parliamentary and Health Service Ombudsman should a complainant wish to escalate their concern. We raised this with the provider who told us that this would be rectified.



Updated 7 May 2019

We rated well-led as Good because:

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities. The strategic approach demonstrated an understanding of local commissioning.
  • The service had developed its vision, values and strategy and one member of staff told us that they felt that the ethos was to deliver outstanding services to patients. At the time of inspection, the service had just undergone a reconfiguration and as part of this process would be reviewing its vision and values.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff informed us that they felt respected, supported and valued. They were proud to work for the service, and felt that they worked well together as a team. In preparation for the CQC inspection the provider had included all staff in preparations including inputting their views into the pre-inspection presentation.
  • The service focused on the needs of patients.
  • Leaders and managers told us that they would act on behaviours and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We heard from the service how they had contacted, recalled and apologised to affected patients following the loss of some clinical samples. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. All staff were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. The service had launched their new operational structure on the day of inspection. This had been carried out to better meet the demands of the service, and gave staff specific roles, responsibilities and duties in key operational areas such as IT governance. The service informed us that they planned to introduce a standardised assurance report for their Quality and Improvement Board to drive improvement and aid consistency and efficiency.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. For example, this included clinical governance, medicines management and financial probity.
  • The systems in place to ensure that emergency medication and equipment were within date and appropriate for use were not operating effectively. Since the inspection we have been informed and sent evidence to support the introduction of a new checking and assurance procedure for emergency medicines and equipment.

Managing risks, issues and performance

There were clear and effective around processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through such as clinical audit. Leaders and managers had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality. The service informed us that they had plans to standardise the format of future audits.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where staff had sufficient access to information.
  • The service used performance information which was reported and monitored. Management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.
  • The service had taken steps to move from a paper based information system to a paperless system to aid efficiency and effectiveness.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, patients could give feedback via a number of routes, these included:

    • Surveys
    • Service specific questionnaires
    • NHS Friends and Family Test submissions
    • General comments and complaints
    • Engagement exercises

  • Staff could describe to us the systems in place to give feedback.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • There were frequent opportunities for staff to meet with the management team, this included via daily meetings or huddles, to more formal meetings and appraisals.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work, this included:

    • The development of internal standards and care pathways.
    • Clinical audit.
    • Reviews of patient feedback.