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.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Phoenix Surgery on 8 March 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients 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.
• Previous feedback from patients said that they did not find it easy to get through to make an appointment in the morning and had not found it easy to make an appointment with a named GP or book appointments in advance.
• The practice had made changes to the appointments system three months prior to the inspection in response to negative feedback and felt that there had been an improvement in patient satisfaction and a decrease in complaints since.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.
• The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider should make improvement are:

To monitor closely and, where appropriate, act on patient feedback regarding access to appointments, the telephone system and specifically access to the GP of choice.

To ensure that all curtains are changed or cleaned on a regular basis.

To continue to monitor QOF results closely and identify and act on any outliers.

To continue to examine the reasons for high levels of exception reporting and where possible act to reduce the levels.

To ensure that all new members of staff have a full induction.

To continue to encourage and facilitate the reinstatement of the Patient Participation Group.

To complete the registration of the new partners.

To monitor childhood immunisation rates to try to improve the uptake for children of 12 months and under.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice