Grove Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first inspection for this practice since its registration with CQC. This key question has been rated as requires improvement. This meant some aspects of the practice were not always well led and there was lack of assurance about some areas of good governance. The practice was in breach of legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a shared vision, strategy and culture but further work was required to embed it fully. The practice had a mission statement which was to be a top-quality health care team. This included working with patients to enable good health, delivering excellent accessible care, continually developing to meet new challenges and providing equitable access, The practice had developed a business plan for 2024 to 2025 to help them achieve this. The plan stated they would be cost effective, and generate income, work in partnership with patients, and be a supportive care team. However, the plan did not include the target dates for completion. The practice had a business continuity plan and disaster recovery plan to allow them to operate under exceptional and adverse circumstances. In addition, we were told the leads held regular meeting to discuss performance and direction however these were informal and not recorded. Staff were offered annual appraisal.

Most of the leaders understood the context in which the practice delivered care, treatment and support. The leaders explained the partners worked at the practice during the week and were accessible to staff. The leaders explained the practice offered flexibility in the hours staff worked to enable them to meet their cultural and caring responsibilities. The staff we spoke with felt supported by the leadership team. The practice had put in place job descriptions for all staff and had ensured staff were aware of their roles and responsibilities. A review of a sample of staff files found the practice was following an improved recruitment process. Staff had access to training and development. The leaders had recently become a partnership and were considering employing a salaried GP.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. All staff had completed their whistleblowing training and there was a whistle-blowing policy in place last reviewed May 2024. The practice had a freedom to speak up guardian for staff to speak to. Staff we spoke with said they would feel comfortable in making their views heard. Bullying and harassment were discussed during practice meetings.

The practice valued diversity in their workforce. The leaders explained that they provided flexible working arrangements and time for staff to follow their religious and cultural beliefs. Most staff had access to continual professional development, support and mentorship. Equality, diversity and inclusion was discussed during practice meetings.

The practice did not always have clear responsibilities, roles, systems of accountability and good governance. Although the practice had a quality assurance and good governance policy and procedure in place, the assessment has found improvements in systems and processes were required for medicines management, responding to safety alerts, staff supervision and competency, safety netting for urgent referrals, the management review of patient’s long term health conditions, and improving access to the practice.

The staff understood their duty to collaborate and work in partnership so that services work seamlessly for people. The practice had shared care agreements in place and carried out referrals, however the monitoring of urgent referrals did not include a system for safety netting. This was responded to by staff during the assessment. There was a patient participation group (PPG) who represented the views of people using the service. We were provided with a copy of the August 2024 meeting, where the GP national survey results were discussed.

During the assessment we found practice staff were focused on continuous learning, and improvement but were unable to describe areas of innovation. The practice annually reviewed the national GP patient survey and put actions in place to improve the service, for example improving the telephone system. The practice had developed a business plan for 2024 to 2025 to help them achieve this. The plan stated they would be cost effective, and generate income, work in partnership with patients and be a supportive care team. In addition, they had a business continuity and disaster recovery plan to respond to exceptional and adverse circumstances.