• Doctor
  • GP practice

The Groves Medical Centre

Overall: Inadequate read more about inspection ratings

171 Clarence Avenue, New Malden, Surrey, KT3 3TX (020) 8336 6565

Provided and run by:
The Groves Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Groves Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Groves Medical Centre, you can give feedback on this service.

Site visit: 27/10/23, Clinical review day 1: 01/11/23, Interview with staff: 07/11/2023, Clinical review day 2: 17/11/23

During a routine inspection

We carried out an announced inspection at The Groves Medical Centre with a site visit on 27 October 2023, interviews with staff on 7 November 2023 and reviews of searches and patient records on 1 November 2023 and 17 November 2023.

Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - requires improvement

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - requires improvement

Well-led - inadequate

After we inspected the practice in May 2015, we rated it as good overall, but as requires improvement for safety, as we found gaps in the systems and processes to manage risk and learn from things that had gone wrong. The practice had addressed the issues by the time we inspected again in June 2016.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Groves Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. We inspected the safe, effective, responsive, and well-led key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • conducting staff interviews using video conferencing
  • completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements)
  • reviewing patient records to identify issues and clarify actions taken by the provider.
  • requesting evidence from the provider.
  • a site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • There were widespread gaps in safety systems and processes, including those to keep people safe, identify and manage risks, assess, prevent and control the spread of infections and safely use medicines and to learn and improve when things went wrong.
  • The overall governance arrangements were ineffective. Practice leaders rolled out new governance structures in early 2023. There was a new Executive Board and 4 governance domains (Finance, People and Workforce planning, Governance and Compliance and Clinical). The governance domains were at different stages of development at the time of the inspection. Although we saw evidence of improvement in some areas, we identified weaknesses in oversight of risk that had not been addressed by the practice’s assurance systems and policies that were not implemented effectively.
  • Leaders had not, when making changes to the service, identified the risks that needed to be considered or had identified the risks but had failed to establish effective means to manage them
  • Some of the safety issues were identified were the same as those we told the practice to address in 2015.
  • The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • Patients’ needs were not always assessed, and care and treatment was not always delivered, in line with current legislation, standards and evidence-based guidance.
  • The practice had not fully complied with the Accessible Information Standard.
  • Reasonable adjustments were made when patients found it hard to access services. The practice had implemented an online triage system, which did not take into account previously agreed individualised adjustments when suggesting appointments. The practice had considered the risk that patients may not be willing or able to use the new system, and had arrangements in place to allow patients to continue calling or visiting the practice. Staff completing the triage tool had access to information about individualised adjustments. However the impact on patients with adjustments who were able to use the system and felt comfortable doing so was not considered, and information on this was not provided for these patients prior to implementation.
  • Complaints were not consistently handled in line with national guidance.
  • The practice had made changes to the service, but was not always fully monitoring the impact on the patient experience or the quality of care. The practice had introduced a new phone system and was monitoring the average wait time per week, but was not routinely reviewing the time taken for patients to get through to the practice at different times. Staff in different advanced clinical roles were seeing more patients who would traditionally have been seen by GPs, but there was insufficient oversight to ensure that the quality and safety of care was maintained
  • Staff told us that they felt well-supported and enjoyed good opportunities for development. The culture was described as positive, and colleagues as friendly and helpful.

Although the practice leaders told us of plans to improve governance arrangements and showed us evidence of some individual systems that had been improved, ratings are based on evidence at the time of inspection.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure there is an effective system for identifying, receiving ,recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

14 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of The Groves Medical Centre on 12 May 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12(1)(a)(d)(e) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 14 June 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and where further improvements have been made since the comprehensive inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Groves Medical Centre on our website at www.cqc.org.uk.

The practice was previously rated as Good overall following the comprehensive inspection, however the practice was rated as Requires improvement for people whose circumstances make them vulnerable. Specifically, following this focussed inspection we now found the practice to be good for providing safe services.

Our key findings across all the areas we inspected were as follows:

  • Risks to patients were assessed and well-managed, specifically those related to health and safety, equipment checks and responding to emergencies.
  • Systems were in place to ensure that safety alerts and significant events were actioned appropriately.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

12 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Groves Medical Centre on12 May 2015.

Overall the practice is rated as good.

Specifically, we found the practice to be good for providing well-led, effective, caring and responsive services. It was rated as requires improvement for providing safe services. It was rated as requires improvement for providing services to the population group for People whose circumstances may make them Vulnerable, and rated as good for the remaining five population groups we report on: Older people; People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students); and People experiencing poor mental health (including dementia).

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were assessed, however not all risk assessments were recorded.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • There was a good skill mix amongst doctors and nursing staff with a number of clinicians having specialised areas of expertise.
  • Patients said they were treated with compassion, dignity and respect by the doctors, and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice could evidence positive outcomes for patients as a result of audits they had completed.
  • The practice achieved 895 points out of a total of 900 for the year 2013/14 (four percentage points above CCG Average and six above England Average).
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for bookable appointments.
  • The practice held regular clinical and non-clinical meetings and minutes were recorded.
  • The practice had sought feedback from staff and patients, and had acted upon that feedback.
  • The practice had achieved above the CCG and national average for childhood immunisations.
  • The practice fell below the CCG and national average for the number of patients who were satisfied with the appointment system and the ease of getting though on the phone.
  • Not all staff were aware where emergency equipment was located, and some equipment was out of date.
  • The practice fell below the CCG and national average for flu vaccinations for patients over 65 years and for those under 65 years in the defined influenza clinical risk groups.
  • A review of patient records indicated there was room for further development of care plans.
  • There were no clear lines of delegation to ensure key tasks were performed when principal staff were absent.

We saw one area of outstanding practice:

  • The practice offered work placements to students from the local Council apprenticeship scheme. These apprentices are enabled to gain a range of skills and training. If they showed an aptitude for the work, where possible they would be offered a permanent position with the opportunity for further training and development. Current and former apprentices who were now permanent employees spoke highly of the opportunities provided by the GP practice.

There were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure all equipment is within its use by date.
  • Ensure all staff know where to find the emergency medicines and nebulisers.
  • Ensure health and safety risk assessments are documented.

In addition the provider should:

  • Ensure all clinical staff receive clinical alerts and minutes of clinical meetings.
  • Record the action taken as a result of learning from significant events.
  • Introduce a process for checking that equipment in GP bags is correctly maintained and all doctors are aware of and follow the practice policy regarding medicines in those bags.
  • Record minutes of the practice governance meetings.
  • Ensure the complaints leaflet is on display in the reception area.
  • Ensure certificates relating to staff training are available.
  • Carry out annual basic life support training.
  • Ensure there are clear lines of delegation to provide a continuity of service when staff are absent.
  • Ensure appropriate care plans are in place where there is an identified need for them.
  • Ensure that patients with a learning disability receive an annual review.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice