Grosvenor House Surgery

We carried out an announced comprehensive inspection at Grosvenor House Surgery on 4 August 2022. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Following our previous inspection on 11 October 2016, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Grosvenor House Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

At this inspection we covered all key questions:

• Are services safe?
• Are services effective?
• Are services caring?
• Are services responsive?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

• Conducting staff interviews
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider

Our findings

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 found:

There was a lack of good governance in most areas.

• Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines.
• Risks to patients were not assessed and well managed in relation to fire safety, infection prevention and control, recruitment checks and emergency medicine.
• The practice had a system in place to manage safety alerts but it did not work effectively as we found some safety alerts were not actioned as required to ensure the safe care and treatment of patients.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
• The fixed electrical installation checks of the premises had not been carried out.
• The practice’s uptake of the national screening programme for cervical cancer screening and childhood immunization uptake was below the national average.
• Patient treatment was not always regularly reviewed and updated.
• There was limited evidence of quality improvement activity. Clinical audits were not carried out.
• People were not able to access the telephone system in a timely manner.
• Annual appraisals were not carried out in a timely manner for some clinical and non-clinical staff.
• There were limited activities to collect patient feedback.
• The Patient Participation Group (PPG) was not active.
• Feedback from patients was positive about the way staff treated people and they said they felt actively involved in decisions about care and treatment.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Continue to encourage the patient for cervical cancer screening and childhood immunisation uptake.
• Establish the Patient Participation Group (PPG).

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services