Grosvenor House Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment in August 2022, we rated this key question as requires improvement. At this assessment in June 2026, the rating has remained the same because we found the issues related to poor governance, leadership, and management at the last assessment had not been followed up on and the risks mitigated. We also found new concerns at this new assessment and the service was in breach of legal regulation in relation to good governance.

This service scored 43 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not show understanding of the challenges and the needs of people and their communities. The culture observed during the site visit and assessment process showed a lack of accountability for the tasks required to ensure safe delivery of primary care. We observed that the practice had not clearly identified who was responsible for specific tasks at the practice and to monitor compliance with guidance and regulations. Patient feedback expressed dissatisfaction with the culture and attitude of staff at the practice. Staff we spoke with expressed their concerns about the work ethics and culture at the practice were not according to the practice’s code of conduct.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Several members of staff told us that they could approach the leaders with their concerns but the necessary support or follow-up was not provided by the leaders increasing the anxiety experienced by staff about performing their roles satisfactorily.

The service attempted to foster a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with the Integrated Care Board in North and West London. However not all staff were aware of the speaking up arrangements and staff told us more needed to be done for appropriate actions to be put in place to encourage staff to speak up.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. This was a concern identified at the last assessment in August 2022 and there had been no improvement. The service did not mitigate the risks identified with staff training, safe recruitment procedures, safe environment and tasks related to safe delivery of primary care. The leaders did not have oversight of administrative tasks and some clinical tasks. Clinical meetings prior to the CQC visit shared with us by the practice lacked details of agenda and discussions and any learning from complaints and significant events. This showed that meeting minutes were not consistently recorded to embed good practice or share learning with staff. The evidence of repeated breaches showed that the practice lacked good governance. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service engaged with the patient population, including the patient participation group (PPG) to improve service delivery in conjunction with community health services and other relevant healthcare professionals.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The practice was not proactive in mitigating the risks identified at the last assessment in August 2022 and evidence seen by CQC showed new concerns related to patient care and safety which showed the practice did not learn from the last assessment to ensure safe care delivery on a consistent and continued basis. There was no quality improvement plan in place to drive improvement in services.