The Groves 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.

At our last inspection, we rated this key question as inadequate. At this assessment the rating has changed to Good.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The practice had taken action on the concerns raised at our last inspection. It had improved its recording and control over significant events with information and learning shared with relevant staff.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and made improvements to the service. Managers encouraged staff to raise concerns when things went wrong.

Staff gave examples where learning from events had been shared. For example, a patient was invited for a vaccination but was not eligible. The practice had a meeting to discuss the situation and promote future awareness.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Referrals and test results were managed in a timely way. There were systems in place for processing information relating to new patients and booking appointments, for example, the practice had implemented an online triage tool to facilitate appointment booking. It responded to concerns raised by some patient groups who struggled to use the tool. The practice continued to allow patients to make appointments in person and by phone. To facilitate this additional staff were made available to answer incoming calls.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that objective. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. It organised regular multidisciplinary team meetings (MDTs) bringing together relevant stakeholder health and welfare professionals to ensure there was consensus of care decision making on behalf of service users. It also held registers of vulnerable patients to ensure they received appropriate care.

Safeguarding policies, which had been updated following our last inspection, were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Data from the GP Patient survey 2024 showed a total of 85% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was below the local average of 92% and national average of 91%. However, during this assessment we received feedback about the practice. None of the 278 patients who provided feedback gave negative comments about their level of involvement in decisions about their care and treatment.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had worked through the concerns raised at our last inspection. In particular, a hazardous substance had been moved to an appropriate location and was stored in a locked storage unit. It was clearly labelled and we saw safety data sheets detailing safe storage and handling.

In addition, a risk assessment review in September 2024 found no issues of concern and the most recent fire drill took place on 29 November 2024. We saw evidence of weekly logs for fire safety checks. The practice had 6 trained fire wardens who received annual training.

There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, there were some gaps in staff files relating to incomplete checks and/or training. The practice was aware of the gaps and was working to ensure all staff files contained all necessary information.

There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Data from the GP Patient survey 2024 showed 95% of respondents had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. This was above the local (93%) and national (92%) averages. Patient feedback we received was positive about the healthcare professionals they came into contact with. For example, one patient told us their consultations were always professional and friendly.

The service had taken positive action to improve its record keeping. All records we looked at showed job descriptions, and all clinical staff records we looked at showed evidence of participation in an appraisal within the last 12 months.

We looked at training records for a range of staff members. All records we looked at showed evidence of training in mental capacity and consent, while all but 1 had received training in basic life support and safeguarding for adults and children. On review we found that the member of staff who had not completed these training modules was on long-term absence from the practice.

However, one staff record we looked at did not contain evidence of proof of identity, one record, for a non-clinical member of staff, did not evidence proof of immunity testing or a risk assessment and 1 non-clinical staff member record did not contain evidence of an appraisal within the last 12 months.

The service had taken action to improve since our last inspection. All clinical staff records we looked at showed evidence of having undertaken IPC training. An independent IPC audit had been carried out by NHS England in July 2024. The audit found the practice was fully compliant with all infection prevention and control audit requirements.

The practice had employed an independent contractor to carry out a legionella risk assessment in September 2024. The report found 5 issues categorised as low-level concerns. Low level risks are defined within the report as “slight risk under abnormal operating conditions”. The practice had resolved 4 of the concerns. The remaining concern stated that the level of risk was acceptable for legionella control purposes. The legionella contractor also reviewed the on-site water temperature testing and noted that the practice had kept good clear records.

We saw disposable privacy curtains being used in clinical rooms, they all had been recently changed and were visibly clean. We confirmed there was a regular cleaning schedule currently in use and that independent cleaning contractors attended daily to carry out cleaning in accordance with the schedule.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During this assessment we looked at medical records for several patient groups, including those requiring regular monitoring we found that the practice was unable to evidence that all patients were receiving treatment and/or monitoring in line with national guidelines. For example, we looked at the records for 5 patients who had been prescribed 2 or more courses of rescue steroids in the last 12 months. We found 2 patients had not received follow-up and one patient had been inappropriately issued a rescue pack when their condition did not justify it.

We also looked at other concerns raised at our last inspection and found the practice had acted on these, including:

• All Patient Specific Directions (PSDs) we looked at were in date and appropriately authorised). PSDs are used to authorise health care assistants (HCAs) to administer medicines.
• All Patient Group Directions (PGDs) we looked at were in date and appropriately authorised. PGDs allow some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber.
• The practice had written authorised scope of practice documents for all non-medical prescribers. These were reviewed during one-to-one meetings to ensure the agreed scope remained appropriate.
• All tubing and masks for use with the oxygen cylinder were stored appropriately and all were in date.
• We looked at 10 staff records and found that all actively engaged members of staff had received up to date training in basic life support (BLS) skills.