Archived: Eltham Palace Surgery

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• 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as Inadequate. At this assessment, the rating remains the same.

The service was in breach of Regulation 17 (Good governance) in relation to governance, management and sustainability. This was because not all risks in relation to clinical safety were managed effectively, and we did not see sufficient evidence of complaints being used to drive improvement and increase quality of care for patients.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At our assessments in May 2023, April 2024 and February 2025, we found there was a breakdown in the relationship between the GP partners which negatively impacted staff at the practice. Staff referred to a toxic working environment.

At this assessment, we found a similar situation. One of the GP partners described how they had worked collaboratively with the business manager and 1 of the salaried GPs at the practice to provide a more stable management team. However, this was implemented without the agreement or involvement of the other GP partner.

The negative relationship between the partners had directly impacted staff satisfaction levels, which was referred to in a culture review completed by an independent external organisation.

People did not always feel they could speak up or that their voice would be heard. For example, staff reported feeling that management did not always take their concerns seriously, and that they did not always feel respected by the management.

All staff we spoke with were aware of the Freedom To Speak Up Guardian and reported they would feel able to approach them if required.

At our last assessment in February 2025, we saw that a number of grievances had been raised by staff within the practice.

At this assessment, some staff reported that grievances continued to be raised against fellow colleagues and that relationships in the working environment remained unsettled.

The practice’s review of culture found staff did not always feel respected by management or that their concerns were taken seriously.

Staff told us they were given time to complete additional learning and training if it brought value to their job role. For example, a member of staff had been supported to gain an independent prescribing qualification.

In our last assessment in February 2025, we found that not all staff were able to name leads within the practice (for example, safeguarding and infection prevention and control leads), and that policies within the practice did not always contain the correct information.

In this assessment all staff we spoke with were able to correctly name who the designated leads were, and all staff members cited within practice policies were currently employed.

However, some issues we identified in February 2025 had not been rectified. The provider had not identified or taken sufficient action regarding risks relating to arrangements for monitoring of patient correspondence, leadership, staff wellbeing, complaints, and medicines optimisation. Governance arrangements were not always effective, and we have found an inability to sustain compliance with regulations since 2023.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The practice did not have consistently effective systems to ensure timely management of referrals and test results.

We received information from external partner agencies working with the practice, expressing concern at the inability of the partners to work together.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. For example, there was no consistently effective system to share learning from complaints or significant events.

The service had access to feedback from patients via the friends and family test. However, we did not see evidence that this was used to drive improvement.

At our last inspection in February 2025, we did not see any evidence of completed (two-cycle) audits. At this assessment, we saw one two-cycle audit had been completed. This audit showed some improvement, however the provider acknowledged further work was needed for this cohort of patients.