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Archived: Cross Hall Surgery Good

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Inspection carried out on 6 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We undertook an announced focused inspection of Cross Hall Surgery on 6 September 2016. We found the practice to be good for providing safe care, and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of Cross Hall Surgery on 18 February 2016. As a result of our findings during that visit, the practice was rated as good for being effective, caring, responsive and well-led, and as requires improvement for being safe and for providing good care for vulnerable patients. We found that the provider had breached Regulation 12 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; safe care and treatment.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focused inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Cross Hall Surgery on our website at

Our key findings across all the areas we inspected were that the practice had met the legal requirements by having:

  • Purchased and installed oxygen and a defibrillator to ensure that they were suitably equipped to manage medical emergencies.

The practice had made additional improvements as follows:

  • Conducted regular fire drills to ensure that staff were updated on the fire evacuation procedure.
  • Provided information on the avenues of support available to patients that were carers.
  • Advertised translation services for patients that did not speak or understand English.
  • Created a register for homeless people so that they could register as patients to receive on-going care at the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 18 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cross Hall Surgery on 18 February 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • The majority of risks to patients were assessed and well managed but the practice did not have oxygen or a defibrillator available and had not conducted a risk assessment in relation to this. They had also failed to conduct regular fire drills, although a drill was conducted shortly after the inspection.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Data showed patient outcomes were in line with local and national averages.
  • The practice had carried out audits which resulted in quality improvements.
  • The majority of patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand, but translation services were not advertised.
  • The majority of patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff, which it acted on.
  • The practice had proactively sought and acted on feedback from patients and had an active patient participation group.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

  • Ensure oxygen is available and all staff know how to use it.

In addition, the provider should:

  • Ensure there is a defibrillator or have an adequate risk assessment in place to mitigate the need to have one available.

  • Ensure regular fire evacuation drills are conducted.

  • Provide information for carers and improve the system for identifying carers.

  • Ensure translation services are advertised and patients are not asked to call other patients in for their appointments.

  • Ensure homeless patients are able to register as patients to receive on-going care.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice