The Phoenix Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that the service’s leadership, management and governance assured high-quality, person-centred care and promoted an open and fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality, human rights, diversity, inclusion and engagement. Staff and leaders understood the challenges and the needs of people and their communities.

All staff had contributed to the development of the service’s vision and strategy, which was kept under review. Leaders monitored and reviewed progress against the delivery of their strategy. The service was aware of local challenges which affected their service, such as the projected increase in the local population over the coming years and was working with partner agencies to address these challenges. Staff and leaders actively promoted equality and diversity and worked to identify the causes of any workforce inequalities. They demonstrated a positive and compassionate listening culture that focused on learning and development.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We looked at systems for ensuring clear responsibilities, roles, systems of accountability and noted positively that an operational manager role had recently been introduced. The lead GP spoke positively about how the post holder had supported recent service improvements focussing on patient recall systems, cervical screening uptake, appointments monitoring and medications reviews. We noted that some of these initiatives had enabled the practice to deploy clinical staff in a more efficient and patient centred manner. The lead GP had also recently set aside time to undertake weekly reviews of governance arrangements and we also saw evidence that recent governance improvements were based on insight from people who used the service. Leaders proactively supported staff and regularly met with them to complete appraisals and performance reviews. Leaders held regular meetings with staff, during which they discussed emerging risks and potential improvements to the service.

However, some of the governance processes we looked at in relation to the 10 assessed quality statements were ineffective. For example, recruitment practices were inconsistent and some staff training had lapsed. In addition, legionella risks had not always been acted upon and Infection Prevention and Control (IPC) auditing arrangements were complex. The practice’s IPC policy also lacked clarity on roles and responsibilities at the practice; although shortly after our inspection we were sent an IPC Policy overview document which clearly outlined roles, responsibilities and auditing arrangements at the practice.
 

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.