The Care Quality Commission
  • Doctor
  • GP practice

Phoenix Surgery

Overall: Requires improvement read more about inspection ratings

Dunwich Drive, Toothill, Swindon, Wiltshire, SN5 8SX (01793) 600400

Provided and run by:
Dr Humaira Ramzan

All Inspections

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

7 September 2022

During a routine inspection

We carried out an announced comprehensive inspection Phoenix Surgery on 7 September 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement,

Effective - requires improvement,

Caring - good,

Responsive - good,

Well-led - requires improvement.

This was the first inspection of the Phoenix Surgery under this provider – Dr Humaira Ramzan since their registration on 31 July 2020.

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 carried out this inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • 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.
  • A short site visit.

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 practice provided care in a way that was not always safe for patients and did not protected them from avoidable harm.
  • Patients with some long-term conditions and/or on high-risk medicines were not reviewed and followed-up as indicated in national guaidance.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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