Grove Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were provided safe care and treatment and protected from avoidable harm. This is the first inspection for this practice since its new registration with CQC. This key question has been rated as requires improvement. This means there was limited assurance about safety in regards to medicines management, safety alerts, and clinical staff competence. The practice was in breach of legal regulation in relation to safe care and treatment and staff competence.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the leaders, listened to concerns about safety and investigated and reported safety events and lessons were learnt, the system to manage central safety alerts was not always effective and this could put patients at potential risk. For example, the practice had a central alerting system policy last reviewed in October 2024. Leaders and staff told us that the pharmacists would act on safety alerts. However, as part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. The searches identified the practice had not followed 3 Medicines and Healthcare products Regulatory Agency (MHRA) alerts. This was raised with the provider during the assessment to enable them to review and take action. Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information to staff. The practice had a significant event policy and procedure in place last reviewed in February 2024. A log of 6 significant events and their investigations were submitted for 2024, these demonstrated the practice had recorded lessons learnt and fully investigated the events.

At the time of the assessment the practice did not have an effective system in place to assure all urgent referrals received a prompt assessment. The practice had a referral policy and procedure in place last reviewed February 2024. This stated that for urgent referrals (two week waits) in order to safety net, electronic reports must be run on a daily basis and the medical secretary or administration must follow up as required, however this was not being followed or recorded. During the assessment the leaders responded to our findings and put a new safety netting system in place for urgent referrals. The system to manage patient test results and clinical correspondence was not always effective. The practice had a policy in place regarding the management of test results and clinical correspondence, last reviewed in October 2024. This did not include a system for the follow up of laboratory results and other correspondence from secondary care. Although the managers explained they checked patient results daily to ensure they were actioned, as part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. These identified laboratory results had not been followed up since February 2023 and some had not been filed since June 2024. At a further site visit on the 4 December, we saw some test results had not been filed from 8 November 2024. A review of 3 found 2 had been actioned and one had not. The practice manager explained they were monitoring the computer system regarding results as it had been faulty. Although the leaders stated they would contact healthcare partners when they had concerns, they did not have regular meetings to discuss and improve outcomes for people with complex needs or with the health visitors to discuss child and adult safeguarding.

The systems to identify review and safeguard patients were not always fully effective. The leaders explained they had not had any regular meetings with external teams to discuss and improve outcomes for safeguarding within the last year, a meeting was planned for January 2025, instead they had contacted the safeguarding team or health visiting team when necessary. The GPs told us they reviewed all the patients who were on the safeguarding registers annually and the practice manager reviewed the list monthly. The practice had a system to follow up children who were not brought to appointments, however the staff did not carry out audits to review the children and identify risks or patterns. The practice policies about safeguarding were available on the practice website. All staff had completed safeguarding training to the appropriate level. The practice had a system to highlight vulnerable, adults and children to staff, however a review of patient records found this had not been completed for one patient.

The practice did not have sufficient checks in place to ensure that receptionists carried out patient triage correctly when patients were being diverted to other services. The receptionists had completed care navigation training and asked patients for a description of their illness and explained they may offer an alternative to the patients’ initial choice, such as the pharmacist or a telephone appointment. Triage guidance was in place for the staff to follow, however at the time of the assessment their calls were not reviewed by the leadership team to ensure they were following guidance. We observed the practice was equipped to respond to medical emergencies, including suspected sepsis and staff were suitably trained in emergency procedures. Staff had completed sepsis, basic life and anaphylaxis training where appropriate.

The practice had mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities, and technology supported the delivery of safe care. We visited the practice, and observed it was well maintained and there were systems to ensure equipment was safe to use. We saw risk assessments were in place for fire safety and legionella, and actions had been taken. The provider told us that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The practice provided evidence of annual portable appliance testing, and calibration of equipment for all sites here were systems for safely managing healthcare waste. Staff explained any maintenance concerns were promptly responded to by the leaders and improvements had been made. All staff had completed their fire safety training and the principles of health and safety training.

Although the practice had carried out the necessary recruitment checks, and ensured staff completed mandatory training, the practice did not always make sure that clinical staff had completed the necessary role specific training and did not provide effective clinical supervision for all clinical staff. We found the practice had not sought prior to the assessment assurances that some clinical staff had completed their role specific training such as asthma, chronic obstructive airways diseases, diabetes, childhood, and travel vaccinations to ensure they were competent to carry out their roles. We reviewed 10 patient consultation records carried out by practice nursing staff and found 8 of the records where guidance was not followed effectively. The practice did not have a system in place to carry out clinical supervision of the practice nurses to ensure competency. The national GP patient survey carried out from January to March 2024 had 119 responses. This found 81% of patients had confidence and trust in the health care professional they saw or spoke to, and 68% stated the health care professional was good at treating the patient with care and concern. In addition, 74% stated that their needs were met. 52% found the receptionists helpful. The patients’ responses for these categories were below the national and local area national averages. We reviewed 4 staff files and found all the necessary checks had been completed. The leaders submitted information to demonstrate staff had completed the necessary mandatory training, such as safeguarding adults and children, infection prevention and control, fire safety and basic life support. Staff had completed annual appraisals, and a partner GP reviewed the pharmacist consultation records monthly to ensure they were following evidence-based guidance.

The practice mostly assessed and managed the risk of infection. We visited the practice and found appropriate standards of cleanliness and hygiene were being met. However, we observed the clinical waste bins were not locked and there were insufficient sharp bins to store sharps prior to their collection and disposal. The practice manager and business partner were the leads for infection control, and they carried out regular infection prevention and controls checks of the premises. In addition, the cleaners carried out daily cleaning and staff carried out daily checks of the rooms they worked in. Staff had completed an infection prevention and control audit and a legionella risk assessment was in place.

Although the practice had a high-risk drug monitoring procedure and process in place we found the practice did not always make sure that medicines and treatments were safe and met people’s needs. As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. Overall, we found the monitoring of patient’s medicines did not always follow national guidelines. For example, we identified 20 patients administered methotrexate we sampled 5 patient records. We found that monitoring was appropriate overall. However, we also found GPs had not recorded the day of the administration of the weekly medicine on prescription form. (The Medicines and Healthcare products Regulatory Agency Published 23 September 2020 guidance advises GPs to decide with the patient which day of the week they will take their methotrexate and note this day down in full on the prescription to prevent taking an accidental overdose). In addition, the drug was not linked in the computer patient record system to the underlying disorder. We also found one patient had been recommended a medicine by secondary care and this had not been prescribed. We identified 939 patients were prescribed a medicine to manage their blood pressure, and 90 may not have had the correct monitoring. We found 20 patients who had not ordered a repeat prescription since 2016 to January 2024 and the practice did not have a robust system in place for identifying patients that were overdue or not ordering the drugs. Following the assessment the provider reviewed the patients and took appropriate actions. In addition, we found that a travel vaccine had been charged for but used out of the NHS stock and risk assessments were not always carried out prior to administering a travel vaccine. The searches also demonstrated some patients had not had an annual review of their medicines, staff said this had been previously identified by the pharmacist.