The Care Quality Commission
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  • GP practice

Archived: Crusader Surgery

Overall: Good read more about inspection ratings

Units 5, 7-8 Crusader Business Park, Stephenson Road West, Clacton On Sea, Essex, CO15 4TN (01255) 688805

Provided and run by:
Crusader Surgery

Important: The provider of this service changed. See new profile

All Inspections

03 March 2017

During a routine inspection

We carried out an announced comprehensive inspection at Crusader Surgery on 28 October 2015 returning five days later on 02 November 2015 to speak with a GP not available at the initial inspection. The practice was rated as inadequate overall and placed in special measures for a period of six months. We took enforcement action against the provider and issued a warning notice to be complied with by March 2016.

We then carried out a follow up inspection on 12 April 2016 to check for compliance with the warning notice. We found that that the practice had complied with the warning notice.

The comprehensive report for 28 October 2015 and 02 November 2015 inspection and the follow up report 12 April 2016 can be found by selecting the ‘all reports’ link for Crusader Surgery on our website at www.cqc.org.uk.

This comprehensive follow-up inspection was carried out on 03 March 2017 following the period of special measures. Overall, the practice is now rated good.

Our key findings were as follows:

  • There was an effective system in place for reporting and recording safety incidents.
  • Risks to patients were documented assessed and well managed.
  • Staff members assessed patients’ needs and delivered care in line with current clinical guidance.
  • Information about how to complain was available at the practice and on their website.
  • We saw staff members had been trained with the skills, knowledge and experience to deliver effective quality care and treatment.
  • Patients told us they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff members felt supported by the GP and practice manager. Since the last inspection, there had been a change of leadership and improvements had been made.
  • The practice 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 practice asked the members of their virtual patient participation group to comment on proposed developments at the practice.

The areas where the provider should make improvement are:

  • The areas where the provider should make improvement are:
  • Promote and encourage a more active patient participation group. Improve cervical screening uptake.
  • Review the accessibility to the practice by telephone and in person to ensure this meets patients needed.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice

12 April 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection over a period of two days at Crusader Surgery on 28 October 2015 and 02 November 2015. The practice was rated as inadequate overall. Specifically they were rated as good for caring and responsive services, requires improvement for effective services and inadequate for safe and well-led services. The practice was placed into special measures for a period of six months.

As a result of our findings at the inspection we issued enforcement action against the provider in the form of a warning notice and to comply with it by March 2016. This related specifically to the following areas of concern;

  • Systems and processes were not set-up to assess monitor and improve the quality and safety of the services provided, this included the quality experienced by the patients using the practice.
  • The provider did not undertake assessments to monitor and mitigate risks relating to the health, safety, and welfare of patients, staff members and others who may be at risk within the practice.
  • Patients that had received home visits at a residential home did not have comprehensive detail recorded within their contemporaneous records. The record of care and treatment that had been provided for the patient including decisions taken in relation to their care and treatment was incomplete in the records at the practice.
  • Staff records had not been maintained in relation to staff members employed at the practice.

Following the inspection on 28 October and 02 November 2015 the practice sent us an action plan that explained what actions they would take to meet the regulations in relation to the warning notice. We then carried out a focused inspection at Crusader Surgery on 12 April 2016 to ensure that the practice had responded appropriately to the warning notice.

Our key findings were as follows:

The practice had:

  • Appointed a lead nurse to act as their designated practice ‘Infection Control Lead’.Infection control audits were undertaken regularly and included hand washing audits.
  • Reviewed and documented their clinical and environmental cleaning procedures. Replaced patient dignity screens and disposable curtains were now in place and documented evidence seen of regular changing.
  • Held practice and clinical team meetings that were minuted, with set agenda items to be discussed at each meeting. All staff members were included in the practice team meetings and received communications regarding safety event outcomes along with any lessons learned. Safety events were appropriately recorded and maintained, with a bi-annual audit and statement produced looking for themes or recurrences.
  • Ensured all patients seen during the bi-weekly residential home visits were updated within the patient computerised records on return to the surgery in a detailed and comprehensive format.
  • Reviewed and updated all the practice policies and procedures to ensure they met current legislation and were up to date.
  • Organised all staff members’ records and job descriptions reflected staff roles, and responsibilities. Disclosure and Barring Service (DBS) checks had been undertaken for all staff members and evidenced in their records. Recruitment procedures and the practice policy had been updated, to meet the regulations and were evidenced when the practice had recruited a new member of staff.
  • Reviewed and analysed their quality data to assess the quality of their service. Where issues had been found the practice had acted on this information. The actions taken had been documented within the team meeting minutes.
  • Recorded and circulated medicine and patient safety alert information to all the relevant staff members. Alert information was documented to evidence whether the practice needed to act on it and this discussed as a standing agenda item at practice meetings and a separate review meeting had been held.
  • Commissioned an external organisation to provide a monitoring system and carry out a fire, health, and safety risk assessment of all practice operational areas.
  • The practice had investigated new telephone system suppliers, and was due to have a new system installed to improve patient experience when accessing the practice by the telephone.

There was one area where the provider should make improvement :

Improve the system in place for monitoring patients on high risk medicines to ensure that reviews undertaken are consistent.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 October 2015 and 02 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crusader Surgery on 28 October and 02 November 2015.

Overall the practice is rated as inadequate. Specifically, we found the practice was good for caring and responsive services, requires improvement for effective services, and inadequate for safe and well-led services. The concerns which led to these rating apply to everyone using the practice, including all the population groups.

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

  • Staff knew how to report incidents, near misses and concerns within the practice. The practice had carried out investigations when things went wrong, however lessons learned from investigations were not communicated to staff members and so safety was not improved.

  • Patients were positive about their interactions with staff and said they were treated with compassion, respect, and dignity.

  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes they had to wait a long time for non-urgent appointments.

  • The practice provided a workers commuter extended hour’s clinic on Monday evenings that could be booked in advance.

  • Specialist drug and alcohol clinics were provided at the practice to meet local area population demand.

  • Patients told us that it was very difficult to get through to the practice on the phone to make an appointment.

The areas where the provider must make improvements are:

  • Take action to review and update the infection prevention and control policy and procedures at the practice. Provide clinical oversight of staff training and support for Infection control.

  • Take action to review the clinical and environmental cleaning procedures at the practice. (In particular the patient screens used to protect patient dignity).

  • Ensure patient medical records match the residential home records with the treatment patients received, when visited in residential care.

  • Practice policies, and processes need to be urgently reviewed to ensure up to date guidance to ensure staffare supported to carry out their roles in a safe and effective manner that are reflective of the of the practice procedures.

  • Ensure there are appropriate assessments and monitoring of patient and environmental risks.

  • Set-up a safety alert receiving and reporting system to ensure these have been acted on and communicated to all staff members appropriately.

  • All staff roles, and responsibilities to be reflected in their job descriptions.

  • Staff must receive regular appraisals and have access to support for any additional training that may be required.

  • DBS checks for all staff providing chaperoning or a risk assessment explaining why DBS is not needed.

The areas where the provider should make improvements are:

  • Ensure recruitment documentation and staff records are organised and kept up to date.

  • Improve access for patients to the surgery via the telephone system.

  • Review safety incidents and complaints to monitor for trends or themes.

  • Improve human resources support to provide practice leadership the capacity to deliver quality service improvements.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 July 2013

During a routine inspection

Crusader Surgery had courteous staff in the reception area and there was plenty of seating for people waiting for appointments.

A selection of information was displayed in the waiting room for the benefit of the patients. This included notices about the surgery services, leaflets on health promotion, safeguarding and other support services.

We received some positive comments from people about the surgery and the staff on the day of inspection. One person told us: "The receptionists are exceptionally good, really helpful."

The staff members we spoke with told us they involved people in their care. One doctor told us: 'We listen to what people have to say then agree with them the approach we're going to take.'

The provider showed us evidence that, assured us the surgery protected people against the risks associated with medicines.

People we spoke with told us they felt safe to be treated at the surgery and felt confident the staff members were experienced in their roles.