The Care Quality Commission
  • Doctor
  • GP practice

Douglas Grove Surgery

Overall: Good read more about inspection ratings

Douglas Grove, Witham, Essex, CM8 1TE

Provided and run by:
Dr O Salau & Dr O Adetunji

All Inspections

During an assessment under our new approach

Date of Assessment: 30 June 2026. Douglas Grove Surgery is a GP practice and delivers services to approximately 6500 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 92.4% White, 2.4% Asian, 2.6% Mixed, 1.9% Black and 0.7% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

Safe: Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience.

Effective: Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.

Caring: Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.

Responsive: People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

Well-led: The service had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes.

During a routine inspection

We carried out an announced comprehensive inspection at Douglas Grove Surgery on 12 December 2018 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall, outstanding for people experiencing poor mental health (including people with dementia) and good for all other population groups.

We found that:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice provided care in a way that kept patients safe and protected them from preventable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice listened to their patients and organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way.
  • The practice continually audited and developed the services they provided to ensure patient outcomes and satisfaction was improved.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Leaders had the capacity and skills to deliver high-quality, sustainable care.
  • Staff told us they felt supported, valued and that management listened to their opinions.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

We rated the population group people experiencing poor mental health (including people with dementia) as outstanding in both effective and responsive because;

  • The practice recognised they had a high prevalence of patients with mental health needs. To manage the needs of this cohort of patients without impacting on the service provision of other population groups, the practice recognised specialist service provision was needed. They made the decision to employ at their expense a specialist mental health nurse to hold a clinic at the practice one day a week for the last 12 months. The practice recognised this would need a whole practice approach and confirmed all staff members had received mental health and dementia training to guarantee they could provide the support patients needed both at reception and on the phone. Staff also told us they understood and were committed to the practice values regarding patients experiencing poor mental health.
  • The specialist nurse could access other services and discuss cases with mental health colleagues to enhance patient’s well-being and help them to remain within primary care. This reduced referring patients into a hospital setting, and ensured people were more effectively managed in primary care.
  • The practice hosted counsellors two days a week from ‘Health in Mind’ which was part of the ‘Adult Improving Access to Psychological Therapies programme’ (IAPT). This hosting arrangement gave clinicians working at the practice the opportunity to seek advice quickly when needed and arrange for counselling support for patients swiftly to improve patient outcomes and reduce further anxiety.
  • Because of all these initiatives the quality performance data for mental health at this practice, exceeded both local and national practice achievement and except reporting was low. We looked at quality data for this population group over time, which showed mental health data had improved over the last four years. We also noted that in the last year all the other population groups had greatly improved quality data showing the initiatives undertaken had improved all patient outcomes and confirmed quality care for all.

Whilst we found no breaches of regulations, the provider should:

  • Improve the identification of carers to enable this group of patients to access care and support when needed.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice