• Doctor
  • Independent doctor

The White Rose Surgery

Overall: Good read more about inspection ratings

Exchange Street, South Elmsall, Pontefract, West Yorkshire, WF9 2RD (01977) 642412

Provided and run by:
Phoenix Health Solutions Limited

Latest inspection summary

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Background to this inspection

Updated 3 August 2023

The White Rose Surgery independent doctors service operates from:

Exchange Street, South Elmsall, Pontefract, West Yorkshire, WF9 2RD. 

We visited this location as part of the inspection. 

The Phoenix Health Solutions Limited at The White Rose Surgery is registered with the Care Quality Commission to deliver the following regulated activities: 

• Diagnostic and screening procedures 

• Treatment of disease, disorder or injury 

• Surgical procedures

The provider delivers a range of activities for NHS patients who are referred either directly through themselves or via a sub-contract with another registered independent provider. 

Services provided under their own Any Qualified Provider (AQP) contract commissioned by NHS West Yorkshire Integrated Care Board include: 

  • Direct Access Adult Hearing Loss
  • Minor Hand Surgery–Carpal Tunnel Service
  • Gastroenterology 
  • Ophthalmology
  • Physiotherapy Services 

Care includes diagnostics, day care, outpatient clinics and aftercare.
 

Services provided under the NHS standard sub-contract to increase waiting list capacity include:

  • Gynaecology 
  • Urodynamics for bladder and incontinence issues.
  • General surgery which includes minor procedures requiring local anaesthetic on a day care basis. 
  • Pain management.
  • Oral and maxillofacial 
  • Ultrasound for gynaecology services.
  • Nerve conduction. 
  • Ear Nose and Throat, diagnosis and management (non-aesthetic). 
  • Neurology
  • Haematology
  • Endocrinology
  • Colorectal
  • Ophthalmology

The provider delivers services from modern facilities. Parking, including parking for those with mobility issues, is available at a car park next to the location. 

Services delivered under their own AQP were for patients who were aged 18 years or over. Services delivered under the sub-contract include patients who are under the age of 18, as well as adults. 

Patients are drawn in general from the Wakefield area. 

In addition to consultation facilities the service has an operating theatre, recovery area, audiology facilities and an endoscopy suite. Home visits are available as part of the adult hearing service.  

The service operates 7 days a week from 8am till 6pm. 

The service is staffed by 4 directors, 3 heads of service, 1 head of operations, 1 business support manager, 1 assistant business support manager, 2 nurses, 2 health care assistants, 11 ward clerks and 1 medical secretary.  Other staff including consultants and other clinicians are provided on a contractual or agency basis. 

The service has a web presence at www.phoenixhealthsolutions.co.uk

How we inspected this service 

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently. 

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. 

Before visiting the service’s locations, we looked at a range of information that we hold about the service. We reviewed information submitted by the service in response to our provider information request and undertook interviews with staff both prior to the inspection visit and during our visit. Before and during our visit, we reviewed documents and clinical records, and made observations relating to the service and the locations it was delivered from. 

This was a focused inspection, and we examined the following 3 questions:

  • Is it safe?
  • Is it effective?
  • Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Overall inspection

Good

Updated 3 August 2023

This service is rated as Good overall. We previously inspected the service in April 2019 when we rated it good overall and for all key questions.

The key questions are rated as:

Are services safe? –   Good

Are services effective? –   Good

Are services well-led? –   Good

We carried out a focused inspection at The White Rose Surgery in response to provider notifications to us of safety incidents linked to failures and errors in patient referrals. During this inspection we therefore examined the key questions of safe, effective and well-led. The key questions of caring and responsive were not examined and retained ratings of good.

CQC inspected the service in April 2019 and asked the provider to make improvements regarding the need to:

  • 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 Control Audit.

We checked these areas as part of this focused inspection and found these points had been actioned. 

The service delivers a range of health and care services including day care, diagnostic services and outpatient clinics and procedures for patients who access the service via an NHS referral. Referrals were either direct into the service or via a sub-contract delivered on behalf of another CQC registered provider.

At the time of the inspection the provider was in the process of appointing a new 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.

Our key findings were:

  • The provider had systems in place to manage the safe and effective delivery of services.
  • When any adverse incidents occurred, we saw that relevant statutory notifications had been made, thorough investigations had been undertaken and that learning and improvements had been put in place to prevent recurrence.
  • The provider routinely reviewed the quality and effectiveness of services provided through clinical audit, and from receipt of patient feedback.
  • Governance procedures were in place, and there were plans to strengthen these in the future.
  • Care and treatment had been delivered in line with evidence-based guidelines.
  • The service had undergone third party audit and accreditation. 

The areas where the provider should make improvements are:

  • Implement regular structured infection prevention and control audits across the organisation.
  • Examine the need to standardise the production of clinical notes in the patient records system to reduce possible delays.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services