The Care Quality Commission
  • Doctor
  • Independent doctor

The White Rose Surgery

Overall: Good read more about inspection ratings

Exchange Street, South Elmsall, Pontefract, West Yorkshire, WF9 2RD (01977) 642412

Provided and run by:
Phoenix Health Solutions Limited

All Inspections

19 July 2023

During an inspection looking at part of the service

This service is rated as Good overall. We previously inspected the service in April 2019 when we rated it good overall and for all key questions.

The key questions are rated as:

Are services safe? –   Good

Are services effective? –   Good

Are services well-led? –   Good

We carried out a focused inspection at The White Rose Surgery in response to provider notifications to us of safety incidents linked to failures and errors in patient referrals. During this inspection we therefore examined the key questions of safe, effective and well-led. The key questions of caring and responsive were not examined and retained ratings of good.

CQC inspected the service in April 2019 and asked the provider to make improvements regarding the need to:

  • Review and improve procedures for the date checking of emergency medicines and equipment. 
  • Review and improve procedures to give greater assurance that consultants had received appropriate annual mandatory training. 
  • Continue to follow up on actions identified in the last Infection Prevention and Control Audit.

We checked these areas as part of this focused inspection and found these points had been actioned. 

The service delivers a range of health and care services including day care, diagnostic services and outpatient clinics and procedures for patients who access the service via an NHS referral. Referrals were either direct into the service or via a sub-contract delivered on behalf of another CQC registered provider.

At the time of the inspection the provider was in the process of appointing a new registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

  • The provider had systems in place to manage the safe and effective delivery of services.
  • When any adverse incidents occurred, we saw that relevant statutory notifications had been made, thorough investigations had been undertaken and that learning and improvements had been put in place to prevent recurrence.
  • The provider routinely reviewed the quality and effectiveness of services provided through clinical audit, and from receipt of patient feedback.
  • Governance procedures were in place, and there were plans to strengthen these in the future.
  • Care and treatment had been delivered in line with evidence-based guidelines.
  • The service had undergone third party audit and accreditation. 

The areas where the provider should make improvements are:

  • Implement regular structured infection prevention and control audits across the organisation.
  • Examine the need to standardise the production of clinical notes in the patient records system to reduce possible delays.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

 

1 April 2019

During a routine inspection

This service is rated as Good overall.

The service had been previously inspected in February 2014. At this time services were not rated.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at The White Rose Surgery as part of our inspection programme.

The service delivers a range of health and care services including day care, diagnostic services and outpatient clinics and procedures for patient who access the service via an NHS referral.

One of the Directors of Phoenix Health Solutions Limited is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service made use of patient feedback as a measure to improve services. They had produced their own surveys and used the NHS Friends and Family Test, and results were analysed on a regular basis. Results obtained from the NHS Friends and Family Test in March 2019 showed that 100% of patients would be extremely likely or likely to recommend the service to others.

We also received 20 Care Quality Commission comment cards. These were all very positive regarding the care delivered by the service, many mentioning the caring and helpful attitude of staff.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines, and supported this work with clinical audits and the analysis of outcomes and performance.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review and improve procedures for the date checking of emergency medicines and equipment.
  • Review and improve procedures to give greater assurance that consultants had received appropriate annual mandatory training.
  • Continue to follow up on actions identified in the last Infection Prevention and Contol Audit.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

11 February 2014

During a routine inspection

We spoke with six patients, who visited the clinic on the day of our inspection. Patients told us they were very happy with the care and support they received. They told us before any treatment was considered their consent was sought. They made comments such as, 'I am always asked if I understand and am ok with things.' 'They are all really helpful and professional here.'

Patients told us they felt included in their consultations and that they felt that they were well cared for by staff at the clinic. One person told us 'I have always felt they really care about you.'

Patients commented that they thought the clinic and practice building were clean.

We reviewed the recruitment and selection processes for new staff and found them to be robust. This ensured that patients were supported by suitably qualified, skilled and experienced staff.

Patients told us that they had not had any need to complain; but if necessary they would speak to the practice manager, doctor or the nurse directly.

21 March 2013

During an inspection looking at part of the service

We carried out this inspection to check that action had been taken to address the concerns identified during our last inspection carried out in August 2012.

During this inspection we found that action had been taken to address our concerns. We found the service had an emergency transfer policy in place to ensure people received appropriate and timely access to emergency care and treatment if required.

The service will be provided with copies of all the relevant pre employment check information which will be held on site within the service from April 2013 as part of the newly agreed contracts with the staff provider agencies.

We found that a governance structure had been agreed and implemented. We saw that the new groups had been formed and terms of reference agreed to take on responsibility for different aspects of the management of risk and improving the quality of the service.

As we had received positive feedback from people spoken with during our last inspection and were following up only on concerns identified in our previous inspection we did not speak with people who used the service during this visit.

9 August 2012

During a routine inspection

The people we spoke with as part of the inspection were positive about the services that they receive. They told us that staff were polite, helpful and that they felt well informed and involved in their care. They were positive about the standard of care they experienced.