Archived: Eltham Palace 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last inspection we rated this key question as Requires Improvement. At this inspection the rating is Inadequate.

Staff were able to name the practice’s Freedom To Speak Up Guardian and reported feeling comfortable approaching certain members of the senior leadership team within the practice with concerns. There were also a number of complaints about one partner from staff and patients. It was unclear what action had been taken to address these concerns, and if the partner involved had been made aware of these complaints. The provider was unable to demonstrate quality improvement through the use of clinical audits. Attempts to improve the working relationship of the 2 GP partners had been unsuccessful, we saw evidence this had a negative impact on patients and staff working in the service.

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 previous inspections in May 2023 and March 2024, we found there was a breakdown in the relationship between the 2 GP partners which negatively impacted staff at the practice. Whilst there had been attempts to improve the relationship, staff continued to refer to a toxic working environment. Some staff told us they did not find all leaders to be approachable.

At this inspection in February 2025, we found a similar situation. Again, we were informed of attempts to improve the working relationship between the 2 partners; however, these were reported by leaders in the practice to have been unsuccessful. A number of staff reported one partner to be difficult to approach for guidance, with other staff naming this partner in resignation letters, stating their behaviour was a contributing factor in their decision to leave the practice. This partner had also been named as the sole reason for the complaint in 11 of 29 complaints received by the practice in the last 12 months. The relationship between the partners had impacted the ability to recruit and retain staff, we saw an example where disagreements about recruitment had resulted in the provider’s inability to recruit a reception manager. This post was yet to be filled at the time of our inspection. Staff told us this impacted their ability to do their role as they were expected to cover this role as well as their own.

At our previous inspection in March 2024, we were not assured that all staff attended meetings or had access to meeting minutes where significant events, patient safety alerts, complaints and safeguarding concerns were discussed. There was a link on the practice’s website directing patients to a complaint form; however, this did not work at the time of the assessment in March 2024.

At this inspection we found improvements had been made. Staff told us they attended meetings where learning events were discussed, and we saw evidence of these discussions in meeting minutes. Patients were able to make complaints using the link on the practice website, or by contacting the practice manager via telephone or in person.

The service did not always work towards a fair culture by improving equality and equity for staff working for them.

We saw that a number of grievances had been raised by staff within the practice. We saw examples of resignation letters where the behaviour of a particular member of the leadership team had been named as a contributing factor in the staff member’s decision to resign. We saw examples of exit interviews where staff had expressed concerns about leadership within the practice. In particular, the inability of the GP partners to agree on decisions made it difficult for staff to know the correct processes to follow.

In-house staff satisfaction surveys were not routinely carried out. It was unclear whether action had been taken by practice leaders to address the concerns raised by staff via resignation letters and exit interviews.

Staff reported that requests for flexible working were not always honoured. We were told staff with external commitments (such as caring responsibilities) were asked to change their working patterns at short notice.

At our previous inspection in March 2024, we found some staff were unable to name the safeguarding leads and the infection prevention and control lead.

At this inspection in February 2025, we found some improvements had been made. Staff were able to identify the safeguarding leads and infection prevention and control lead.

We found that some of the risks identified at previous inspections had been addressed. These included: monitoring of patients with long term conditions; management of medicines requiring monitoring; safety alerts; medicine reviews; fire safety; access to appointments; and staff training.

However, we also found some risks remained. We requested 11 policies as part of our inspection. We found 7 of these policies contained incorrect information; for example, staff who no longer worked at the practice were named in the policy. One policy appeared to have not been reviewed since February 2017, despite having a recommended date for review as February 2019. Following our inspection, the provider showed us evidence that the policies identified had been updated and contained correct information.

The provider had not identified or taken action regarding risks relating to: arrangements for monitoring of patient correspondence; leadership; staff wellbeing; complaints; infection prevention and control; and monitoring of emergency equipment. The provider’s governance arrangements were not always effective and we found an inability to sustain compliance since 2023.

At our previous inspection in March 2024, we were not assured that all staff attended meetings or had access to meeting minutes where significant events, patient safety alerts, complaints and safeguarding concerns were discussed. There was a link on the practice’s website directing patients to a complaint form; however, this did not work at the time of the assessment in March 2024.

At this inspection we found improvements had been made. Staff told us they attended meetings where learning events were discussed, and we saw evidence of these discussions in meeting minutes. Patients were able to make complaints using the link on the practice website, or by contacting the practice manager via telephone or in person.

At our previous inspection in March 2024, it was unclear whether learning from significant events and complaints was used to drive improvement, as not all staff knew how to access meeting minutes where these matters were discussed and recorded.

At this inspection in February 2025, staff were able to share examples of significant events and complaints and told us how they could access meeting minutes.

The provider had collected feedback from the practice’s PPG; however, had not undertaken any surveys either with the wider patient population or with staff working at the practice.

We did not see evidence of any two-cycle audits that had been completed by the provider. Therefore, the provider was unable to demonstrate quality improvement through the use of clinical audits.