- GP practice
Crusader Surgery
Important:
The provider of this service changed - see old profile
All Inspections
05 December 2022
During a routine inspection
We carried out an announced inspection at Crusader Surgery on 05 December 2022. Overall, the practice is rated as requires improvement.
The ratings for each key question are:
Safe - Good
Effective – Good
Caring – Requires Improvement
Responsive – Requires Improvement
Well-led - Good
Following our previous inspection on 01 March 2022, the practice was rated requires improvement overall and for safe, effective and responsive key questions, good for caring and inadequate for well-led key questions. As a result of the concerns identified, we issued a Section 29 warning notice on 20 April 2022 in relation to a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
This subsequent comprehensive follow-up inspection was carried out to assess compliance with the breaches identified in the warning notice and other concerns identified.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Crusader Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up on breaches of regulation from our previous inspection.
The focus of this inspection included:
- All the key questions.
- The breach of regulations, and ‘shoulds’ identified in the previous inspection.
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.
- Evidence sent following the 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 had been fully engaged with the external support provided by the Integrated Care Board. They had made clear improvements. These improvements had been implemented, embedded and monitored to ensure improvements would be sustained.
- Safeguarding systems were effective, and staff had been appropriately trained.
- There were appropriate standards of cleanliness and hygiene.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, we found some potential missed diagnosis and a few overlooked monitoring aspects within the medicine reviews. The practice acted quickly to address identified issues and reviewed and updated processes to reduce recurrence.
- Health and safety risk assessments reflected the actions taken to improve.
- A revised reporting process had improved the practice ability to ensure patient safety alerts including historical alerts were acted on in a timely manner to keep patients safe.
- Patients received effective care and treatment that met their needs.
- There was a quality improvement programme, that included clinical and administrative audits.
- Staff dealt with patients with kindness and respect however, satisfaction within the national GP survey was low for involving them in decisions about their care.
- There was low satisfaction of patients in the GP national survey regarding access to care and treatment in a timely way.
- Governance systems to manage risk, performance and quality and sustainability were effective.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Review the frequency of infection control audits in order to identify and act on any issues.
- Continue to monitor historical patient safety alerts with the new reporting process.
- Continue to reduce multiple psychotropic prescribing.
- Review the effectiveness of the work to improve the uptake of childhood immunisation and cervical screening.
- Take steps to always record learning against all significant events documented.
- Review the effectiveness of the work to improve patient satisfaction regarding confidence and trust in the healthcare professional they saw or spoke with including involving them as much as they wanted in decisions about their care and treatment. Also the work to improve access to someone at the GP practice via the telephone, and the overall experience of making an appointment at suitable times.
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
01 March 2022
During a routine inspection
We carried out an announced inspection at Crusader Surgery on 1 March 2022. Overall, the practice is rated as requires improvement
The ratings for each key question are:
Safe - Requires Improvement
Effective – Requires Improvement
Caring – Good
Responsive – Requires Improvement
Well-led - Inadequate
Following our previous inspection on 03 March 2017, the practice was rated Good overall and for all key questions:
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Crusader Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This was a comprehensive inspection undertaken to follow-up on:
- Concerns raised following a quality visit by the local clinical commissioning group. They found issues relating to a lack of effective systems, processes, appointments and access to the practice via the telephone.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
- Evidence sent following the 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 have rated this practice requires improvement overall
We found that:
- Safeguarding systems were effective. Staff had been appropriately trained.
- There was a lack of information available to support reception staff to identify patients with the signs of sepsis or in deteriorating health.
- Controlled drug systems required strengthening to ensure prescribing processes kept people safe.
- There were appropriate standards of cleanliness and hygiene.
- Health and safety risk assessments did not reflect the actions taken to improve.
- Patients taking high-risk medicines were not being reviewed effectively. Patient safety alerts were not always being actioned in a timely manner.
- Some patients with long-term conditions had not been reviewed effectively. Clinically vulnerable patients had not been effectively identified and prioritised for care during the COVID-19 pandemic.
- There was no quality improvement programme, including clinical audit.
- Staff treated patients with kindness and respect.
- Patient satisfaction with phone access and appointments was low. A new phone system had been purchased and additional staff employed to achieve improvements.
- The system for managing complaints was not effective.
- The practice did not have a clear vision, strategy or succession plan.
- Governance systems to manage risk, performance and quality and sustainability were not effective.
- The leadership at the practice was not effective.
We found one breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Continue to provide information to staff to support them with the identification of patients with suspected sepsis or deteriorating illness.
- Undertake a review of controlled drug prescribing to ensure that guidelines are being followed.
- Continue to improve the system for acting on patient safety alerts.
- Record the learning and action taken from the analysis of significant events.
- Continue to improve childhood immunisation and cervical screening uptake.
- Complete the audit of the number of unplanned admissions and readmissions to A&E and act on any findings.
- Continue to improve patient satisfaction with access to the practice, including appointments, and make improvements where required.
- Develop a system for involving staff and patients to provide feedback about the services provided.
- Improve the leadership at the practice and provide a vision, strategy and monitor progress.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care