Grovehurst Surgery

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

The practice did not have established systems in place to manage fire safety checks of routine emergency lighting. Improvements were required in the monitoring of some high-risk medicines. There were no formal arrangements to assess the competency of some prescribers, and no established system in place for managing historical safety alerts.

The provider had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. There were enough staff with the right skills, qualifications and experience. The practice had established and effective systems in place to keep vulnerable children and adults safe.

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 provider 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.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety and patient care was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave patients support. Learning from incidents and complaints was shared with relevant staff to help prevent recurrence. For example, the provider introduced a three-stage checking process to safeguard against potential data breaches.

The provider actively engaged with patients and healthcare partners to establish and sustain robust systems of care, where safety was consistently managed and monitored. Their commitment to patient safety was evident through well-structured processes maintained in collaboration with staff and external services. Continuity of care was prioritised, particularly during transitions between services, ensuring patients experienced coordinated support throughout their care journey.

There were systems in place for processing information relating to new patients. The provider worked with other healthcare professionals to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

There were systems and processes in place to flag records for vulnerable children and adults. A review of children safeguarding records showed that alerts were appropriately placed on clinical records.

Staff had access to adult and children safeguarding leads in the practice and could also escalate concerns externally if required. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns, working in partnership with other organisations.

There were notices in the practice showing that chaperones were available if required. We saw that staff who acted as a chaperone were trained for the role and had received a disclosure and barring service check (DBS). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

Staff told us if children or vulnerable individuals were not brought to their appointments or failed to attend, this would be identified for follow up action. Staff told us this approach helped ensure that early warning signs were not missed and that necessary interventions could be put in place.

The provider worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and what to do should their condition deteriorated.

In the 2025 national GP patient survey, 94% of respondents reported being involved in decisions about their care. This result is higher than the local average of 90% and the national average of 91%.

There were not established and effective systems in place to mitigate, manage or remove some risks. We found the provider had failed to take timely action on all areas identified as requiring action in their health and safety (HS), and fire risk assessments. Their HS risk assessment dated July 2024 identified the emergency lighting system needed to be replaced. In their fire risk assessment dated August 2025, it was identified monthly checks were required for emergency lights. The provider was unable to demonstrate that these actions were completed. The provider acknowledged the issue and advised that next steps would be discussed as part of their ongoing improvement planning. Following assessment, the provider told us an electrician had been scheduled to complete remedial works on 16 October 2025.

A fire, health and safety risk assessment dated August 2025 was in place. Staff had completed annual fire safety training and staff appointed as fire wardens received appropriate training.

They maintained equipment and technology supported the delivery of safe care. Routine legionella testing, portable appliance testing and equipment calibration were routinely conducted by an external company.

The practice had supervision arrangements in place for staff in advanced clinical roles. However, there was not an established system in place to assess the competency of some prescribers to ensure safe practice.

Following our assessment, the provider recognised areas for improvement and presented a plan outlining their intended actions moving forward. However, these actions had not been embedded at the time of assessment, so we were unable to assess the impact of these changes.

The provider made sure there were enough qualified, skilled and experienced staff.

There were a range of clinical and non-clinical roles in the practice. We found training was up to date, learning needs and development of staff was managed appropriately. Safe recruitment practices were followed.

The provider identified, assessed and managed the risk of infection. They mitigated the risk of it spreading and shared concerns with appropriate agencies promptly.

There was a designated infection, prevention and control lead and staff had received relevant training.

The provider completed its annual infection prevention and control audit in July 2025, which identified areas for improvement, including environmental issues like chipped paint. We saw an action plan with achievable timescales to address concerns.

The practice employed an external cleaner, and we saw that cleaning schedules and Control of Substances Hazardous to Health (COSHH) risk assessments were maintained. Cleaning schedules were in place and followed.

Staff had access to gloves, aprons and masks to mitigate the risk of infection to patients. Policies were in place that outlined how staff should triage and manage patients with potentially contagious diseases.

Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to patients.

There were not established and effective systems in place for monitoring of some patients receiving medicines typically used to treat high blood pressure. Our remote clinical searches conducted on 11 September 2025 identified there were potentially 48 patients who had not been monitored. We reviewed a sample of 5 patient records and found all 5 had not been monitored in line with national guidance.

Medicine reviews were not consistently conducted in line with best practice guidance. We found in 3 of the 5 patient records reviewed, they did not include supporting detail and showed no evidence of a structured assessment. This did not align with best practice guidance.

The provider was unable to evidence that all Medicine and Healthcare products Regulatory Agency (MHRA) alerts had been appropriately reviewed and actioned. Whilst alerts were sent to the designated staff member and through the practice’s online management platform, there was no clear evidence that all historical searches had been completed. While a log was available on the practice’s system, it did not include records of historical alerts, making it unclear whether these had been reviewed and acted on. The absence of a written policy outlining the process further contributed to uncertainty regarding staff roles and responsibilities in the management and response to safety alerts. However, staff demonstrated a good understanding of managing recentclinical alerts, and there was clear evidence that appropriate and timely actions had been taken in response to these.

The provider acknowledged improvements were required and presented a plan outlining their intended actions moving forward. However, these actions had not been embedded at the time of assessment, so we were unable to assess the impact of these changes.

Medicines were stored securely, and staff regularly checked the stock levels and expiry dates for all medicines. There were appropriate systems in place to ensure the safe storage of medical gases, such as oxygen.

There were systems and processes in place to monitor fridge temperatures to maintain the integrity of stored medicines.

The provider had a system to securely manage prescription stationary.