Archived: The Phoenix Surgery

We previously carried out an announced comprehensive inspection at The Phoenix Surgery on 25 January 2019. The overall rating for the practice was requires improvement. This was because staff had not received essential training and governance arrangements needed to be strengthened. The full comprehensive report on the 25 January inspection can be found by selecting the ‘all reports’ link for The Phoenix Surgery on our website at .

After the inspection in January 2019 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

We carried out an unannounced comprehensive inspection at The Phoenix Surgery on 5 and 11 November 2019. This was in response to concerns raised and to follow up on breaches of regulations identified at our previous inspection in January 2019.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for providing effective, caring, responsive and well-led services. It is rated as requires improvement for providing safe services. The practice is rated as good for all population groups.

We rated the practice good for providing effective, caring, responsive and well-led services because:

• The practice had 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The premises were clean and hygienic.
• Risks to patients, staff and visitors were assessed, monitored and managed in an effective manner.
• The practice sought feedback from patients, which it acted on.
• Staff had undertaken essential training and were encouraged to develop in their roles.
• Staff were positive about working in the practice and felt valued and supported in their roles.

We rated the practice requires improvement for providing safe services because:

• The management of medicines did not always keep patents safe.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients

The areas where the provider should make improvements are:

• Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
• Put measures in place to reduce exception reporting rates where they are higher than average.
• Continue to address areas of lower than average patient satisfaction in the national GP patient survey results.
• Put measures in place to encourage the identification of carers so that appropriate support can be offered.
• Ensure that the infection control lead undertakes training for the role and attends clinical commissioning group events for infection control lead nurses.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at The Phoenix Surgery on 25 January 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected.
• Information from our ongoing monitoring of data about services.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and requires improvement for the effective and well-led domains. The practice is rated good for the safe, caring and responsive domains.

All population groups have been rated as requires improvement.

We rated the practice good for providing safe, caring and responsive because:

• The practice had 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The premises were clean and hygienic.
• Risks to patients, staff and visitors were assessed, monitored and managed in an effective manner.
• The practice sought feedback from patients, which it acted on.

We rated the practice requires improvement for effective because:

• Not all staff had been trained to provide them with the skills and knowledge and experience to deliver effective care and treatment.

These areas affected all population groups so we rated all population groups as requires improvement for effective.

We rated the practice requires improvement for well-led because:

• We saw little evidence of systems and processes for learning, continuous improvement and innovation.
• The practice did not always act on appropriate and accurate information.
• The practice culture did not always drive high quality, sustainable care.

The areas where the provider must make improvements are:

• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development necessary to enable them to carry out the duties.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Increase the uptake of childhood vaccinations for children under 1 year so that the 90% target is achieved
• Improve the uptake for cervical screening to ensure at least 80% coverage in line with the national target.
• Put measures in place to reduce exception reporting rates where they are higher than average.
• Review the process for monitoring patients’ health in relation to the use of medicines including high risk medicines to ensure it is fail safe.
• Ensure details of the ombudsman are included in all response letters to complaints.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.