The Care Quality Commission
  • Doctor
  • GP practice

Crouch Oak Family Practice Also known as The Crouch Oak Family Practice

Overall: Good read more about inspection ratings

45 Station Road, Addlestone, Surrey, KT15 2BH (01932) 840123

Provided and run by:
Crouch Oak Family Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Crouch Oak Family Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Crouch Oak Family Practice, you can give feedback on this service.

9 July 2019

During an annual regulatory review

We reviewed the information available to us about Crouch Oak Family Practice on 9 July 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

5 July 2019

During an annual regulatory review

We reviewed the information available to us about Crouch Oak Family Practice on 5 July 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

18 May 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Crouch Oak Family Practice on 6 October 2015. Breaches of legal requirements were found during that inspection within the safe and well-led domains. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:

  • Recruitment information being available for each person employed. This included completing Disclosure and Barring Service (DBS) checks for staff whose roles required them to have one, proof of identity and references.
  • The on-going development and implementation of systems and processes in place for effective governance including assessing, monitoring, and driving improvement in the quality and safety of the services provided, as well as mitigating any risk.
  • Ensure assessments for legionella and gas safety had taken place.

We undertook this focused inspection on 18 May 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as Good under the safe and well-led domains. This report only covers our findings in relation to those requirements.

  • Recruitment files contained the required information which included evidence of Disclosure and Barring Service (DBS) checks for those staff who needed them, proof of identity and references.

Systems and processes were in place for effective governance. Including:

  • staff recruitment files staffing levels and staffing structure
  • development of a new employee handbook and new contracts for staff
  • induction checklists and appraisal systems
  • training requirements for staff and implementing new e-learning modules

Evidence was seen for building safety assessments including legionella, fire, electrical and gas safety.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

6 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crouch Oak Family Practice. Overall the practice is rated as Requires Improvement.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • Urgent appointments were available on the day they were requested.
  • The practice was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure.
  • The practice proactively sought feedback from staff and patients, which it acted on.

We noted several areas of concern that were the responsibility of the landlord of the building - NHS Property Services. Our concerns included:-

  • The building being in a poor state of decoration and repair – including noticeable holes in walls and there was a poor state of flooring
  • No adequate heating control within the server room – risk of overheating and fire
  • Lack of management plan for asbestos
  • Lack of maintenance and update of clinical rooms – including rooms which were now too small for their purpose.
  • Outside storage for general waste not lockable or secure.
  • Lack of legionella assessment and no management plan in place
  • No evidence of a current gas safety certificate

Prior to our inspection the practice had conducted risk assessments (including health and safety, fire risk and infection control assessment) to highlight to NHS Property Services the areas that needed addressing.

However there were areas of practice where the provider must make improvements:

Importantly the provider must:

  • Ensure that recruitment information is available for each person employed. This includes completing Disclosure and Barring Service (DBS) checks for those staff who need them, proof of identity and references
  • Ensure the on-going development and implementation of the systems and processes in place for effective governance including assessing, monitoring, and driving improvement in the quality and safety of the services provided as well as mitigating any risk.
  • As there was a potential risk to patients the provider must ensure assessments for legionella and gas safety take place and are provided with a copy of certificates .

Additionally the provider should:

  • Continue to communicate with the landlord of the building, NHS Property Services, in order to rectify some of the concerns raised by the provider and by CQC during the inspection. NHS Property Services to complete the necessary risk assessments and supply the necessary documentation in order to ascertain the safe running of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice