During an assessment under our new approach
Date of Assessment: Remote clinical searches were carried out on 17 June 2026 and the site visit took place on 22 June 2026.
Grosvenor House Surgery is a GP Practice registered as a partnership with the CQC registration since April 2013. The practice was last assessed in August 2022, rated as requires improvement overall and issued 3 requirement notices (now called action plan requests) for breaches of Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 19 (Fit and proper persons employed). This announced comprehensive assessment was undertaken because of the previous rating, the concerns found at the last assessment and information of concern made available to CQC.
Grosvenor House Surgery is a GP Practice that delivers General Medical Service (GMS) to approximately 5,180 patients in the London Borough of Ealing under a contract held with NHS England. The National General Practice Profile states that the population make up for this location is 55.3% White, 18.4% Asian, 11.2% Black, 6.6% Mixed and 8.4% other non-white ethnic groups.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population is in the 3rd decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others. This practice is in the third decile indicating it is in a more deprived area on the national scale. 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.
The assessment process findings are as follows:
There were concerns with how people and staff were kept safe and protected from harm and abuse. The practice recorded significant events and shared learning with staff to support ongoing improvement. Not all risks were understood and managed appropriately by the team. Adults at risk of abuse and harm were not identified on the clinical record system and there was no adult safeguarding register at the practice. There was no evidence that routine audits of emergency medicines and emergency equipment were carried out. In addition, there were gaps in staff training, safe recruitment practices, staff appraisals and in monitoring the safety of the environment. For example, there were outstanding actions yet to be completed from the fire safety and legionella risk assessments carried out in December 2025.
People were involved in the assessment of their needs. Patients were invited for their health checks reviews. However, care plans for people with learning disability and /or autism and people with mental health conditions were not personalised or complete. The practice generally delivered services in line with good practice. The practice worked with relevant stakeholders to achieve best outcomes for the patient population. Information was shared with the patients to ensure they made an informed decision about their health care needs. There was a system of recall for patients who did not engage with cervical screening and childhood immunisations; however, the impact of the system of recall was not yet known.
People were treated with kindness and compassion by the clinical staff. The dignity and privacy of patients were respected. Staff did not feel valued and appreciated. Staff wellbeing was not treated with the utmost importance by the service.
People received services that were in line with the Equality Act. Interpreting services were made available to patients who needed them. Complaints were handled appropriately and in a timely manner, however, information on other routes of escalation were not given to the patients.
The leadership and the management of the practice shared a vision of the practice with the staff. The leadership and management had a clear understanding of equality, human rights and safe compassionate care. However, not all staff understood their roles and responsibilities nor felt supported. There were gaps in governance and oversight arrangements. In particular, there was insufficient monitoring of administrative tasks to ensure compliance with the regulation as identified from the previous breaches of regulation to address the concerns. In addition, there was a lack of formal auditing of emergency medicines and emergency equipment within the practice.
We found repeated breaches of regulation in relation to safe care and treatment (Regulation 12) and good governance (Regulation 17). In instances where the Care Quality Commission (CQC) has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
We have asked the provider for an action plan in response to the concerns found at this assessment.