We carried out an announced comprehensive inspection at Crook Log Surgery on 10 June 2016 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was good overall and requires improvement for providing a responsive service.

This inspection was an unannounced inspection, following concerns raised with CQC, which we undertook on 27 March 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements.

The practice was rated as inadequate for the safe and well-led key questions. This led to an overall rating of inadequate. Breaches of legal requirements were found, and requirement notices were issued in relation to patient safety, staffing and governance.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Crook Log Surgery on our website at www.cqc.org.uk.

We have rated this practice as inadequate overall and requires improvement for all population groups due to significant issues affecting all these groups.

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 and the public.

We rated the practice as inadequate for providing safe services because:

• The practice did not have clear and effective processes for managing risks, issues and performance.
• Staff did not all have safeguarding, fire and infection control training.
• Necessary recruitment checks including references had not been undertaken for all staff.
• Not all staff had evidence of their immunisation status on file.
• Clinic curtains had not been cleaned since December 2017.
• The practice had provided their reception staff with guidance about when patients should be

prioritised for medical attention.

We rated the practice as inadequate for providing well-led services because:

• There was a lack of governance arrangements to ensure that quality assurance processes were in place which led to improvements in patient outcomes.
• The practice culture did not effectively support high-quality sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• Practice policies had not been updated within the required timeframe and contained out-of-date information.

We rated the practice as requires improvement for providing effective services because:

• The provider had not taken steps to ensure staff had the knowledge to carry out their roles.
• We were not shown evidence of any quality improvement activity taking place at the practice.
• Childhood immunisation uptake was below target.

We rated the practice as good for providing a caring service because:

• Data from the GP Patient survey showed that the practice was in-line with local and national averages in indicators relating to patients’ experience of the practice.
• The practice had identified 2% of the patients as being a carer.

We rated the practice as requires improvement for providing a responsive service because:

• Data from the national GP patient survey showed patients rated the practice lower than others for some aspects accessibility to the service and their overall experience.
• Complaints were not responded to in a timely manner and were not used to improve the quality of care.

The areas where the provider must make improvements are:

• 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.
• Ensure that persons employed at the practice have received appropriate training.

The areas where the provider should make improvements are:

• Continue to take steps to increase the uptake of all standard childhood immunisations and cervical screening.
• Proactively contact those patients who they knew had been bereaved due to the death of one of their patients.
• Review arrangements in place to enable staff to respond to medical emergencies, in particular, their ability to identify patients with sepsis.
• Review the process in place for the safe handling of requests for repeat medicines to ensure persons who are responsible for this role are adequately trained.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service.

This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 12 August 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(2)(c) and regulation 19(1)(b) and (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focussed inspection on 10 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Crook Log Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as good. Specifically, following the focussed inspection we found the practice to be good for providing safe, and well led services. The practice is rated as requires improvement for responsive.

As we found the practice to be good for providing safe, and well led services, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

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

• Recruitment practices included all necessary pre-employment checks completed for all staff.

• Staff had completed basic life support training at required intervals.

• Risk assessments were carried out regarding non-clinical staff who carried out chaperoning duties while waiting for a DBS check, and training ensured they understood their role.

• There was a clear procedure for support when reception staff are subjected to verbal abuse from patients

• Children’s pads were available for use with the practice defibrillator.

• Patient survey data showed the practice remained below national and local averages in a number of areas.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crook Log Surgery on 12 August 2015. Overall the practice is rated as requires improvement.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework (QOF) data, this relates to the most recent information available to the CQC at that time.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough. People received an explanation and a verbal and written apology.
• Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
• Data showed patient outcomes were below the local and national averages in a number of areas.
• Audits had been carried out and showed evidence that they were driving improvements in performance to improve patient outcomes.
• Patients’ comments were positive about the care and treatment they received from clinical staff but they were not always positive about reception staff.
• Information about services provided was available and generally accessible to patients.
• Urgent appointments were generally available on the day they were requested.
• The practice had a range of policies and procedures to govern activity, which were reviewed and accessible to staff.
• The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvements are:

• Ensure recruitment practices include all necessary pre-employment checks being completed for all staff.

• Ensure all staff complete updated basic life support training at required intervals.

• Carry out a risk assessment regarding non-clinical staff who carry out chaperoning duties not having a DBS check and ensure they complete training to ensure they understand their role

In addition the provider should:

• Clarify the procedure for support when reception staff are subjected to verbal abuse from patients.

• Ensure children’s pads are available for use with the defibrillator.

• Review staffing levels to ensure they are sufficient to meet patients needs.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We carried out this inspection to ensure that the provider had completed the required improvements and addressed the areas of non-compliance found at our inspection on the 13 and 19 February 2014.

People we spoke with were generally happy with the care they received although people did say that they were still experiencing difficulties with the telephone lines and in getting through to speak to staff. One person told us "I cannot talk highly enough about this practice, I give my GP ten out of ten" and another described the care they received as "good” although they said they didn’t often need to come to the surgery". We found that people felt listened to by the general practitioners (GPs)

At the inspection on the 29 July 2014 we found that the provider had made the required improvements. We found that people were protected from abuse as the staff had received the appropriate safeguarding training for children and adults and that there were appropriate recruitment checks in place to ensure only suitable people were employed. The practice had made improvements to ensure the quality of the service was monitored and that information was disseminated to all staff to ensure that learning from complaints and significant events took place.

People we spoke with gave mixed views about the care they received but most people were generally happy with the treatment they received from the surgery. One person told us "I cannot talk highly enough about this practice" and another described the care they received as "good". We found that most people felt listened to by the general practitioners (GPs) and other staff at the practice although some people told us that they felt there was a lack of consistency regarding the care they received as they were not always able to see the same doctor. Some people told us that there had been a lot of changes in medical and nursing staff which had affected care. A few people said they had difficulty getting through on the telephone or getting an appointment and there were sometimes long waits to be seen by the doctors. People also said they were not always kept informed if the GP was running late with appointments.

A person said "the GP always listens to me and we have been coming here for a very long time". Most people felt they were treated with respect by the GPs but some people felt that some of the reception staff were abrupt and rude.

We found that people were consulted with and involved in their care in most cases and that people's needs were assessed and care was planned in a way that met these needs. There were child protection procedures and policies in place; however the provider did not have policies and procedures in place for safeguarding of vulnerable adults. The practice had not in all cases taken steps to ensure only suitable people were employed at the service as employment checks were not carried out consistently. The practice had some systems in place to ensure the quality of the service was monitored but the provider was unable to demonstrate that the learning from complaints and significant events had been shared with other staff at the practice.