Grosvenor House Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. At our last assessment in August 2022, we rated this key question as requires improvement.

At this assessment, the rating remains requires improvement. we found that the issues identified with the effectiveness of patient safety and clinical care at the last assessment in August 2022 had not been completely followed up on nor the risks mitigated. We also found new concerns related to assessing patient needs and at this assessment in June 2026.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. Feedback from people using the service was both positive and negative. Feedback received from experience of care online forms from the patients was negative. It mentioned how people felt they treated rudely by the staff, that staff culture was less than positive, and elderly patients were digitally excluded. Care plans for people with learning disability and autism were not reviewed effectively to embed all required information about the wellbeing and health goals of the patients. For example, we found there were incomplete sections of the templated care plans where there was no information about the next health check date and agreed health goals This was also observed for patients with mental health needs; an example was a patient on quetiapine whose medication review was not completed after the strength of the medicine was reduced from a higher strength to a lower one in September 2025. The provider did not check if the patient had adjusted to the change.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Patients with caring responsibilities were offered support and flu vaccinations including signposting to other relevant support services.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The service did not meet national targets for cervical screening and childhood immunisations. The percentage of women aged 25-49 who had an adequate cervical screening test was 62.4% which was below the 80% national target. The percentage of women aged 50-64 who had an adequate cervical screening test was 75.0% which was below the 80% national target. This concern was also identified at the last assessment in August 2022.The service was below the target uptake rates (90%) in all categories of childhood immunisations. The provider was achieving childhood immunisation uptake rates of 79.1% – 83.7% for children aged 2 and 83.3% for children aged 5. The service was achieving immunisation uptake for children aged 1 (77.5%) and MMR (measles, mumps and rubella) uptake for children aged 2 (MMR category) was 81.4%. A recall system was in place to engage patients who had not responded to health interventions, providing education on the associated health benefits. However, the impact of the recall on the uptake was yet to be known. This was also identified at the last assessment in August 2022.

The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.Staff did not always understand and apply legislation relating to consent. Capacity and consent were not clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were not appropriate and not made in line with relevant legislation. Our review of seven DNACPR records showed that there was no process of review of the decisions made while patients were admitted at the hospitals to ensure it remained valid and current to the patient’s needs. We found a DNACPR that did not show the details of the patient it concerned or the clinician who authorised it. This patient was discharged 18 May 2026 and did not have any follow up with the patient completed until 22 June 2026.