- GP practice
Grayshott Surgery
Assessment report published 1 August 2025
Contents
Ratings
Our view of the service
Date of Assessment: 19 May 2025 to 30 May 2025. Grayshott Surgery is a GP practice and delivers service to approximately 12,350 patients under a contract held with NHS England. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 10th decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others. 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.
We carried out carried out this assessment to follow up on concerns identified during our previous inspection in May 2023. At the last inspection we found concerns related to the delivery of safe care and treatment, premises and equipment, staffing and with the provider’s governance systems. At this assessment we assessed all quality statements across the safe, effective and well-led key questions and combined the scores for these areas with scores from the last inspection. Since the last inspection, the provider had made improvements and is no longer in breach of regulations in relation to safe care and treatment, premises and equipment and staffing. However, the concerns surrounding quality assurance and records meant the provider remained in breach of regulation in relation to good governance.
Leaders promoted a proactive and positive culture of safety, based on openness and honesty. However, we found this culture was not always embedded into practice. This was because whilst systems and processes were in place, the processes for identifying, recording and managing significant events were not always consistently followed. For example, staff described incidents which had not been recorded centrally had not been recorded and investigated in a timely manner. We saw evidence that since the last assessment the provider had made improvements and demonstrated a commitment to continue improving the way they managed risks, however, this was not yet fully embedded into practice. The facilities and equipment met the needs of people who used the service. There were enough staff with the right skills, qualifications and experience. Managers made sure staff employed directly by the provider received training appropriate to their role. However, safe recruitment processes were not always followed. Staff managed medicines well and involved people in planning any changes. We saw that since the last assessment the provider had made improvements to ensure that patients now received the necessary monitoring for prescribed medicines and people with long term conditions were monitored in line with best practice guidance. We saw that these systems were well embedded and used consistently in practice.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. They supported people in managing their health and well-being to maximise their independence, choice and control. Care was based on latest evidence and good practice. The service worked well across teams and services to support people. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. The service supported staff wellbeing and staff told us they were valued by leaders and were positive about the support they received. Staff understood their roles and responsibilities. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of innovation, where some pilots which had been led by the service demonstrated a positive impact and had been replicated in other local GP practices.
People's experience of this service
We received feedback from less than 10 people who use the service and the feedback we received was mixed. People were generally positive about the quality of their care and treatment. However, some people described difficulties in accessing care and said they did not feel listened to when raising concerns. Recent survey results, including from the National GP Patient Survey and the NHS Friends and Family Test, showed people were satisfied with services. There was an active patient participation group (PPG) who represented the views of people using the service.