1 December 2022
During an inspection looking at part of the service
We carried out an announced focused desk-based review of Phoenix Surgery on 1 December 2022 to follow up on the Warning Notice issued to the provider following our inspection in September 2022 in regard to a breach of Regulation 12: Safe care and treatment.
This inspection was not rated therefore the ratings from our last inspection in September 2022 remain the same.
Safe - Requires Improvement
Effective - Requires Improvement
Caring - Good
Responsive - Good
Well-led - Requires Improvement
Following our previous inspection in September 2022, the practice was rated Requires Improvement overall.
We also issued the provider with a requirement notice for breach of Regulation 17: Good Governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Phoenix Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook a desk-based review to monitor the provider’s progress against their action plan to confirm the practice had met the legal requirements in relation to the Warning Notice served at our previous inspection in September 2022.
How we carried out the inspection
This remote desk-based review included:
- Conducting staff interviews using video conferencing facilities.
- Completing clinical searches on the practice’s patient records system. (This was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
Our findings
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 found that:
- The provider had implemented an action plan in response to our Warning Notice and was making progress to achieve all of its identified actions.
- The practice had made improvements to how it provided care in relation to high-risk medicines and long-term conditions, for example, we found all patients prescribed DOACs had received their required monitoring.
- Patients with long-term conditions were being contacted by the practice and invited to attend their review.
- We found improvements to the practice’s safeguarding register and how patients on the register had been reviewed.
We found no breaches of regulations. However, the provider should:
- Continue to implement the action plan so all patients receive appropriate monitoring in line with national guidance.
Details of our findings and the evidence supporting our ratings are set out in the evidence table.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services