The Grove Medical Centre

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. The service was in breach of legal regulations because they did not ensure effective systems and processes to ensure good governance in accordance with the fundamental standards of care. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement. This meant leaders and managers did not always have effective oversight of systems and processes to promote safe service provision. New systems had recently been implemented; however, further work was needed to embed some systems. For example, the management of safeguarding and infection control. Staff had not always followed practice policies on prescribing, health and safety, recruitment checks, staff training and annual appraisals. The provider acknowledged these findings and stated that key processes have been reviewed and reinforced following our feedback.

This service scored 61 (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 had a shared vision, strategy and culture. Staff we spoke with shared the provider’s desire to deliver high quality patient-centred care and foster a strong partnership with patients to achieve the best possible health outcomes. Leaders and staff understood their patient population, their cultural needs and challenges.

Staff told us they felt well supported by their leaders. All staff had contributed to the development of the service’s vision, which was kept under review. The service had a mission to provide safe, compassionate, responsive and high-quality healthcare that placed patients at the centre of everything they did. The service had developed values that would help them achieve this vision. The values included delivering patient centered care, compassion and kindness, safety and quality. Staff demonstrated a well-developed understanding of equality and diversity, and how to prioritise safe, high-quality care.

Staff told us leaders in the practice was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

Leaders we spoke with understood the importance of protecting individuals from discrimination and promoting equality in the workplace. Leaders told us they worked to foster a culture of staff wellbeing. Most staff told us they were happy working at the service and that leaders were approachable and responded to any concerns raised. However, 4 members of non-clinical staff reported feeling overwhelmed due to high workload. Managers told us they listened to staff concerns and needs and appropriate adjustments were made where possible. The practice had carried out a staff survey to ensure staff views are reflected in the planning and delivery of services.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had an independent Freedom to Speak Up Guardian for staff to speak with. Staff we spoke with said they would feel comfortable in making their views heard. The practice had a whistleblowing policy last reviewed in November 2025.

The service valued diversity in their workforce. They worked 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.

Leaders provided training and resources to ensure staff were aware of their rights, including those related to equality, dignity, and respect in the workplace. Leaders told us they valued and supported all team members. Leaders held regular meetings where staff could raise concerns. Staff reported being supported if they were struggling at work. Staff members told us they felt encouraged to contribute their ideas.

Staff did not always follow the systems in place to ensure good governance. For example, leaders had not ensured that staff always followed prescribing policies and evidence-based guidelines. Systems were not effective in identifying, mitigating and monitoring risk related to patients and staff including health and safety. The processes in place did not ensure that recommendations from risk assessments related to the premises were completed. For example, fire safety. Managers and staff had not followed the practice policies in relation to infection control, recruitment checks, staff training and managers had not met with all staff annually, to complete appraisals and performance reviews.

Regular searches of the clinical record system were being run to identify patient needs and ensure these were being met. However, our review of clinical records showed that this was not always effective. Consistency in the monitoring of people’s medicines was needed to make sure blood tests were carried out prior to a review or prescription being issued.

Staff we spoke with knew who the relevant lead person was for areas such as safeguarding, infection control and significant events monitoring. Staff took patient confidentiality and information security seriously. Leaders were prioritising succession planning as a partner planned to retire in the next few years, to ensure the continued delivery of high-quality care.

Staff could access all required policies and procedures. Managers held regular practice meetings during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

Since our assessment, the provider informed us of improvements they have made in response to our findings, in relation to governance and management of risks. We will review these changes at the next assessment to see if they are effective and have become embedded into practice.

The practice was part of the local primary care network, and the lead GP attended their meetings. Staff worked with other practices within their primary care network to offer extended access, referral to rapid response, domiciliary phlebotomy for housebound patients and flu, shingles and covid vaccination programmes. At the time of the assessment, staff explained they were not engaged in any local community projects to improve the practice and quality of care for the local population.The safeguarding lead who took over the role last year, told us they participated in multi-disciplinary safeguarding meetings but did not regularly attend meetings with external healthcare partners to discuss learning and improve outcomes for safeguarding. The GP Partner who had previously been the safeguarding lead told us they had regularly attended meetings and safeguarding education events organised by the NEL ICB, and learning was shared with the practice team.

There was a patient participation group (PPG) who represented the views of people using the service. We were provided with a copy of the latest meeting minutes for October 2025, and we spoke with members of the group who stated staff were open and listened to their feedback.

Leaders focused on continuous learning and improvement across the organisation and local system. Leaders told us they had focused on making improvements to their systems and processes so they could provide better and safer care. However, this meant they had not engaged fully in innovation projects.

Staff told us they felt proud to be a training service. The service had 1 qualified GP trainer and 2 GP registrars. Leaders took staff development seriously. For example, leaders had supported a member of nursing staff to achieve a COPD accreditation and another member of staff who had started working at the service as a receptionist to become a Health Care Assistant and they were now a member of the practice team. Leaders held 3 monthly consultant specialist training sessions open to all clinicians.

The service provided evidence of clinical and non-clinical audits which actively contributed to safe, effective practice and research. All staff were encouraged to put forward and test out new ways of working. The practice had completed a QI project to ensure patients on long-term bisphosphonates received an appropriate treatment review in line with national guidance. The outcome demonstrated improvement in patient safety, prescribing and alignment with national guidance.

Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted quickly on issues we identified. Following our inspection, leaders immediately sent us their response to our findings and told us they had reflected and would review ways to improve processes to ensure all staff and managers consistently followed practice policies.