Grosvenor House Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment in August 2022, we rated this key question as requires improvement. At this assessment, the rating remains requires improvement. At our last assessment in August 2022, we found the service was in breach of legal regulation in relation to safe care and treatment. This was repeated at this assessment in June 2026. We found issues related to safeguarding, safe environments, emergency medicines and emergency equipment. We found that some required items were not available for use in the event of a medical emergency and staff training was not up to date.

This service scored 44 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety. Complaints and significant events were recorded but lessons were not learnt to continually identify and embed good practice. This was shown by the evidence of repeated breaches for concerns known from the previous assessment.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately. Safeguarding policies were in place and known to staff, but the policy did not reflect daily practice, for example in relation to the frequency of safeguarding training. The practice did not maintain a list of vulnerable people. The service did not code adult patients who were at risk of abuse and harm. After the site visit, the service told us that the affected patients had now been coded on the clinical system.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Not all emergency equipment was available and maintained. For example, not all items recommended by the Resuscitation Council UK, needed for resuscitation, were in place and the risk assessment presented by the service to support rationale or decision to not have them did not sufficiently consider the risks and impacts. Items not available included portable suction, oropharyngeal airway devices in different sizes, self-inflating bag with reservoir (adult child), clear face masks in different sizes, supraglottic airway device, thermometer, sphygmomanometer, pulse oximeter. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, recommended actions from the fire safety risk assessment completed December 2025 had not been completed. This was also identified at the last assessment in August 2022. In addition, there was no process to ensure visitors on the premises were accounted for. Contracts were in place to ensure the premises were maintained; however, the provider was in the process of changing the cleaning company. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. For example, staff appraisals were not carried out regularly or consistently across all staff groups. They did not work together well to provide safe care that met people’s individual needs and did not follow standard operating procedures or the practice’s staff handbook. There were not a sufficient range of clinical and non-clinical roles within the practice. For example, staff with administrative roles were asked to cover the reception due to lack of sufficient receptionists which created additional workload for the staff and increased their stress level. We found training was not up to date, learning needs and development of staff was not managed appropriately.

Several of the staff told us that there was a shortage of staff which had impacted the wellbeing of the staff. In addition, we found that documentation of staff prior to employment was not robust to ensure safe recruitment processes. This was a concern identified at the last assessment in August 2022. Following the site visit, the service shared recruitment documents obtained from the staff by the new practice management who had been in the process of implementing changes since September 2025.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The practice had only recently appointed a designated infection, prevention and control (IPC) lead. Not all staff had had relevant training. Cleaning schedules were in place but not always followed as indicated by the IPC audit completed in June 2026. Risk assessments and audits were completed, but recommended actions from Legionella risk assessment completed December 2025 had not been completed to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. However, we found that the process could be better managed and improved. For example, the log sheet did not include the date the box of blank prescription sheets was opened, but the serial numbers of prescription sheets in each clinical room was included.

Patient group directions (PGDs) were not always current. We found 3 PGDs had expired. The service could not explain the rationale for nurses using patient specific directions (PSDs) instead of the PGDs for Vitamin B12 injections.Following the site visit, the service provided additional information on administration of Vitamin B12 under a PSD.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. We found no evidence staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with the local and national averages. There was a programme of clinical audits that focused on improving care and treatment.