The Grove Medical Centre

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. Staff felt safe to raise concerns and incidents were investigated. However, people were not always protected through effective risk management. Managers had not ensured staff received regular training and appraisals to support the delivery of high-quality care. Staff mostly managed medicines safely. However, staff did not always carry out patients’ blood tests and physical checks prior to a review or prescription being issued. The service was in breach of legal regulations relating to health and safety, staff training and recruitment and patient monitoring and adherence to clinical guidance. The provider acknowledged these findings and stated that key processes have been reviewed and reinforced following our feedback. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires improvement.

Leaders acknowledged the safety concerns we identified during the assessment and took them very seriously. After the assessment, the provider informed us of actions they had taken to strengthen systems and processes. We will review these at our next assessment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had systems to learn from incidents and improve services. Staff felt able to raise safety concerns, investigated events, and shared learning to help embed best practice. The whole team discussed and learnt from clinical issues. The service held weekly clinical team meetings to discuss any cases of concern and we saw these meetings were recorded. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The service had a duty of candour policy in place. A member of the Patient Participation Group confirmed the provider took concerns seriously and acted to improve the service.

The service had a system in place to receive, share and act on safety alerts. We saw evidence of clinical audits in response to Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

Staff made sure there was continuity of care, including when people moved between different services. The service had robust systems in place to ensure information was effectively shared across teams and agencies, enabling the delivery of safe, coordinated care. There was a system in place to ensure referrals to specialist services were documented and contained the required information. The practice had a newly diagnosed spreadsheet to safety-net newly diagnosed people and to log that the patient had been booked for a consultation appointment with their GP. Referrals and test results were managed promptly enabling the delivery of safe, coordinated care.

Communications from secondary care, such as discharge summaries, were processed efficiently to ensure continuity of care. The service had a new patient registration policy and there were systems in place for processing information relating to new patients.

The service had systems and processes in place to safeguard adults and children from abuse. Staff reviewed practice safeguarding registers for both children and adults. Staff ran regular safeguarding searches of patient records which looked for all registered patients whose records had a safeguarding code applied.

We reviewed the practice’s management of safeguarding. Leaders told us they had introduced a new safeguarding spreadsheet in December 2025, which was still being developed. The safeguarding lead, who had taken over the role in the last year, said improvements were underway to ensure all safeguarding reports were coded accurately.

An administrative staff member was responsible for monitoring safeguarding registers to ensure patients were seen by healthcare staff. The safeguarding lead met with the safeguarding administration lead every two weeks to review coding and ensure records were accurate. Safeguarding alerts were added to clinical records when relevant, enabling staff to identify concerns and respond appropriately, including working with partner agencies. All staff knew who the safeguarding lead was, how to escalate concerns, and how to act if they suspected a patient was at risk. Training records showed all staff had completed safeguarding training appropriate to their roles.

The safeguarding policy had been reviewed by the manager support lead in November 2025. The policy set out the process for raising and sending a safeguarding concern and included a link to the North East London Safeguarding Handbook. However, the safeguarding policy did not contain the name of the practice safeguarding lead. There was no list of recommended safeguarding codes to ensure vulnerable patients could be identified by staff. Following our assessment, leaders told us the safeguarding policy had been updated to include the names of the safeguarding lead and deputy and also a flowchart to guide staff in escalating and managing concerns. Leaders also told us that safeguarding codes had been reviewed and standardised to improve consistency.

Staff we spoke with told us the service had a Was Not Brought (WNB) protocol and that they would always follow up on children and vulnerable adults who missed appointments or who did not attend at prearranged appointments. However, the safeguarding lead told us they had not yet carried out an annual audit of children who were not brought to appointments, or an audit of attendances at accident and emergency services to identify any patterns which may indicate neglect. Following our assessment, leaders told us the practice participated in a monthly meeting with the health visitor to discuss children who were deemed to be vulnerable which included children who fitted into the category of WNB or were frequent attendees at AE services.

Staff had identified risks within the care environment, ensuring equipment, facilities, and technology supported delivery of safe care. The service was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. All staff had been trained in basic life support. Staff provided an example in which they dealt with a medical emergency (patient collapsing) in the practice.

The service operated an online consultation service to help triage patient queries and appointment requests. The service had guidance for staff to identify and escalate risk to an appropriate clinician. The service had developed an on-call duty GP rota, to enable the prioritisation of patients with urgent needs.

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, the service did not have a system to document risks relating to health and safety. There was no comprehensive action plan for managing all identified risks.

Health and safety audits and risk assessments, including electrical, gas, and Legionella had been completed within the past 12 months, however, not all identified risks had been addressed. For example, identified risks from the fire risk assessment were not being managed effectively. There was no evidence that all the fire assessor’s recommendations had been actioned. We found the practice did not have a risk register to monitor progress of the fire assessor’s recommendations. Since this assessment, the provider informed us of improvements they were making to ensure effective monitoring of safety risks. We will review these changes at our next assessment.

Although the surgery building was over 50 years old the provider had carried out some refurbishment, and we found the premises were clean and tidy. Maintenance contracts were in place to ensure the premises were maintained to keep everyone safe. The provider told us that equipment was maintained according to manufacturers’ instructions. The practice provided evidence of annual portable appliance testing, and calibration of equipment. Most staff had completed their mandatory fire safety training. The service had a business continuity plan which was monitored and reviewed. Staff reported no concerns regarding health and safety arrangements.

Learning needs and development of staff was not always managed appropriately. Although the provider used computer software to track mandatory staff training, some staff had not completed training. For example, we checked staff files and found 5 members of staff who had not completed health and safety training, one non-clinical member of staff had not completed fire safety or sepsis awareness training.

Managers had not consistently followed recruitment check processes. On the day of our inspection, some recruitment records were missing. For example, there was no record of employment references or proof of identity for a clinical member of staff. Following our inspection, managers told us a reference was found which was then put on the system. Managers told us that a second reference had previously been requested but no response was received. All staff whose files we reviewed had a DBS check recorded.

Staff vaccinations were not always kept up to date in line with Green Book guidance. 3 out of 5 clinical staff files we checked lacked immunisation histories. Some relevant immunisation information had not been collected for a member of nursing staff. Another clinician had no MMR recorded and no record of a blood test done to check levels. A third clinician had low immunity but had been referred to Occupational Health. A new immunisation log had been introduced, and most staff had completed hepatitis B screening and vaccination. At the time, we saw managers were still completing risk assessments for staff. Managers had completed risk assessments for three non‑clinical staff who declined vaccination.

Some staff had not received an annual appraisal. It was not clear whether managers had identified this. We identified 4 members of non-clinical staff who had not had an annual appraisal. Following our inspection, the service told us they would review their processes to ensure appraisals are completed annually for all staff. There was monthly protected learning time which supported professional development. The service had enough staff.

The practice had a clinical supervision policy. Clinical staff received support and supervision. We saw that clinicians had daily debrief sessions with a senior GP. Where clinical consultations had been discussed with a GP, this was recorded in the patient record. Leaders told us they had conducted an audit of consultations for GPs who worked at the practice. However, there was no record of any audit of the practice nurses’ consultations. Following our inspection, leaders told us they would implement regular audits for the practice nurses. The leaders told us staff always worked within their job descriptions and competencies. However, we reviewed a job description for a GP assistant which was not specific enough to ensure the member of staff worked within their competency.

Where people had specialist needs, such as, a learning disability, staff who’s files we checked had received training to support these people safely.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. For example, although the facilities and premises were clean, there was no record that regular IPC audits were routinely carried out to manage infection control risks to ensure compliance with the infection control policy. The service last had an NHSE Infection prevention and control (IPC) audit in October 2024, and managers told us the action plan from this audit was regularly reviewed. There was evidence that managers had acted on some of the assessor’s recommendations from the 2024 NHSE IPC audit. Managers told us the next NHSE IPC audit would have been due in October 2025, but the practice were still waiting formal notification. Leaders told us they were in the process of arranging an IPC audit through their local PCN.

The service had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place, and staff told us regular checks of cleaning were conducted to maintain standards. The provider had created a new purpose-built storage space so cleaning equipment could be stored safely and according to best practice. Clinical waste, sharps, and clinical specimens were managed appropriately to keep everyone safe.

Staff vaccinations were not always kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. For example, we found records of staff immunisation were partially documented for 3 members of staff, two of which were clinical staff; this risk had been identified during a previous NHSE Infection prevention and control audit in April 2024, but we saw the service had partially responded to this. We saw evidence of risk assessments documented for these staff members. There was a policy for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, and to review if the service was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance.

We reviewed clinical records for patients who had been prescribed medicines which required monitoring. Our review showed that regular medicines reviews were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

We found, overall, there was appropriate monitoring of patients on high-risk drugs and long-term conditions. However, our clinical searches identified staff had not always followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

For example,

Only 4 of 49 patients prescribed ACE inhibitors had up‑to‑date monitoring, and one patient required follow‑up to complete an overdue blood test. Of 55 patients prescribed NSAIDs, 7 lacked GI protection. Our review of five records showed all but one had been appropriately chased regarding PPI use; the remaining patient required further follow‑up to ensure gastroprotection was considered and documented.

The service carried out clinical audits of prescribing that focused on improving care and treatment. For example, the service had shared learning from two-cycle audits of prescribing in response to combination drug safety alerts.

The service had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance. The GP partner had completed the TARGET Antimicrobial Stewardship Self-Assessment Checklist in October 2024. The practice pharmacist had carried out an amoxicillin prescribing audit covering January 2023 to January 2024. The aim of the audit was to identify how the service could improve prescribing of amoxicillin. A re-audit was completed in 2025 which demonstrated prescribing in line with NEL antimicrobial guidelines had improved from 43% compliance to 100%.

Medicines and emergency medicines were stored, administered, and recorded securely, and staff managed prescription stationery appropriately. Staff stored medical gases, such as oxygen, safely. The provider had systems to manage and respond to safety alerts and medicine recalls.