This practice is rated as Requires Improvement. 11/2016 – Good

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? -Requires Improvement

We carried out an announced comprehensive inspection at Phoenix Medical Centre as a part of our inspection programme.

At this inspection we found:

• The practice had clear 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.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was a strong focus on continuous learning at all levels of the organisation.
• The maintenance and management of the premises did not promote the health and well-being of patients.
• Patients were not given sufficient opportunities to be involved in the development of the service.
• A system was not in place to ensure verbal complaints and concerns were always documented.
• Medicines management needed to improve.
• Insufficient action was taken to audit and monitor the standard of the services provided.

The areas where the provider must make improvements as they are in breach of regulations are:

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

• Ensure all premises used by the service provider is fit for use.
• 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:

• Complete risk assessments in relation to the emergency medicines which are not held at the practice.
• Take action to ensure sepsis training for all staff.
• Review the safeguarding policy to ensure it includes information about identifying and responding to all types of abuse.
• Ensure sharp bins are dated when they are assembled.
• Take action to monitor whether consent is gained appropriately.
• Review how the care and treatment offered to patients with mental health needs including dementia is planned and recorded.
• put a system in place to record all verbal complaints and concerns are documented to ensure these are well managed. 

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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

We carried out an announced comprehensive inspection at this practice on the 24th March 2015 and at this time the practice was rated as requires improvement.

Breaches of two legal requirements were also found. We issued requirement notices as a result of our findings and requested an action plan. After the comprehensive inspection the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Fit and proper persons employed and

Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and equipment.

On the 12 May 2016 we carried out a focused follow up visit of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This review took place to check whether the provider had completed the improvements identified during the comprehensive inspection carried out in March 2015.

This report covers our findings in relation to those requirements and areas considered for improvement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Phoenix Medical Centre on our website at www.cqc.org.uk.

The findings of this review were as follows:

• The practice had addressed the issues identified during the previous inspection.

• Appropriate recruitment checks had been carried out for staff. The practice had undertaken Disclosure and Barring Service (DBS) checks for all staff members.

• Environmental risk assessments had been carried out including an up to date fire risk assessment.

• Refurbishment work had started within the practice and included the installation of radiator covers and a baby changing facility installed within the patient’s toilet area. The practice had a maintenance plan to show a planned approach to all work needed within the building.

• Training had been arranged for staff to include safeguarding, accidents and incident reporting.

• They had taken action to improve their management and overview of how they planned their clinical audits.

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Phoenix Medical Centre on 24 March 2015. Overall the practice is rated as Requires Improvement.

Our key findings across all the areas we inspected were as follows:

• Systems were in place to ensure incidents and significant events were identified, investigated and reported. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents though no formal training had taken place. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• The premises required improvement, the risks associated with the building were not regularly risk assessed.
• Patients’ needs were assessed and care was planned and delivered in line with best practice guidance. Staff had received training appropriate for their roles and any further training needs had been identified and planned.
• Patients spoke highly about the practice and its staff. They said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available on the same day.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Action the provider MUST take to improve:

• Ensure full and complete required information relating to workers is obtained and held when recruiting staff. This must include a Disclosure and Barring Service (DBS) check for all staff with chaperoning responsibilities.
• Ensure that staff and patients are protected against risks associated with unsafe premises. This must include implementing a system for identifying, assessing and managing risks associated with the building. Such as access and the security of the building. A local fire safety risk assessment for the practice must be carried out. The practice must develop a planned and preventative maintenance programme for the building.

Importantly the provider should;

• Provide adverse incidents, errors, near misses training and guidance to all staff.
• Ensure all staff undertake vulnerable adult safeguarding training.
• Implement a system for regular clinical audit leading to improvements in clinical care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice