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Inspection carried out on 1 April 2019

During a routine inspection

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 carried out on 11 February 2014

During a routine inspection

We spoke with six patients, who visited the clinic on the day of our inspection. Patients told us they were very happy with the care and support they received. They told us before any treatment was considered their consent was sought. They made comments such as, “I am always asked if I understand and am ok with things.” “They are all really helpful and professional here.”

Patients told us they felt included in their consultations and that they felt that they were well cared for by staff at the clinic. One person told us “I have always felt they really care about you.”

Patients commented that they thought the clinic and practice building were clean.

We reviewed the recruitment and selection processes for new staff and found them to be robust. This ensured that patients were supported by suitably qualified, skilled and experienced staff.

Patients told us that they had not had any need to complain; but if necessary they would speak to the practice manager, doctor or the nurse directly.

Inspection carried out on 21 March 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection to check that action had been taken to address the concerns identified during our last inspection carried out in August 2012.

During this inspection we found that action had been taken to address our concerns. We found the service had an emergency transfer policy in place to ensure people received appropriate and timely access to emergency care and treatment if required.

The service will be provided with copies of all the relevant pre employment check information which will be held on site within the service from April 2013 as part of the newly agreed contracts with the staff provider agencies.

We found that a governance structure had been agreed and implemented. We saw that the new groups had been formed and terms of reference agreed to take on responsibility for different aspects of the management of risk and improving the quality of the service.

As we had received positive feedback from people spoken with during our last inspection and were following up only on concerns identified in our previous inspection we did not speak with people who used the service during this visit.

Inspection carried out on 9 August 2012

During a routine inspection

The people we spoke with as part of the inspection were positive about the services that they receive. They told us that staff were polite, helpful and that they felt well informed and involved in their care. They were positive about the standard of care they experienced.