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Reports


Review carried out on 8 July 2021

During a monthly review of our data

We carried out a review of the data available to us about The Grove Surgery on 8 July 2021. 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 Grove Surgery, you can give feedback on this service.

Inspection carried out on 1 October 2020

During an inspection looking at part of the service

We carried out an announced inspection at The Grove Surgery on 1 October 2019. The overall rating for the practice was good with the practice rated as requires improvement for being safe.

From the inspection on 1 October 2019, the practice was told they must:

  • Ensure care and treatment is provided in a safe way to patients.

In addition, the practice was told they should:

  • Continue to monitor the practice’s performance, in particular the number of patients being excepted.
  • Encourage improved uptake of national cancer screening initiatives and childhood immunisations amongst the practice population.
  • Ensure all staff complete sepsis awareness training.
  • Accurately record smoking status for patients.

The full comprehensive report on the inspection carried out in October 2019 can be found by selecting the ‘all reports’ link for The Grove Surgery on our website at www.cqc.org.uk.

This inspection was a desk top follow up focused inspection undertaken on 1 October 2020 as part of our inspection programme to follow up on concerns identified at our previous inspection.

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

  • documentation and information submitted by the provider.
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

  • The practice had made improvements to the treatment room as required to ensure compliance with Infection Prevention and Control (IPC) standards.
  • Individual staff immunisation status had been checked and recorded in a central spreadsheet by the practice. This showed evidence of vaccination for all current staff.
  • All staff had completed sepsis awareness training.
  • Published data reviewed from the Quality and Outcomes framework (01/04/2018 to 31/03/2019) showed exception reporting was still high for the practice, comparative to local and national averages. The practice advised they had worked hard to improve patient uptake and expected the data to reflect positive improvements when next published.
  • Similarly, the practice advised they had taken active steps to encourage patient uptake of national cancer screening initiatives and childhood immunisations amongst the practice population through targeted discussions and information displayed in the practice. Although the challenges of their patient population remained, they anticipated some improvement would be reflected in the data when next published.

The areas where the provider should make improvements are:

  • Continue to monitor the practice’s performance, in particular the number of patients being excepted.
  • Encourage improved uptake of national cancer screening initiatives and childhood immunisations amongst the practice population.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 1 October 2019

During an inspection looking at part of the service

We carried out an announced inspection at The Grove Surgery on 1 October 2019 as part of our inspection programme. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well-led

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 have rated this practice as good overall and good for all population groups. The practice was rated as requires improvement for providing safe services.

We found that:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We rated the practice as requires improvement for providing safe services because:

  • Systems and processes to reduce risks to patient and staff safety needed strengthening.
  • Risks to patients and staff had not adequately been assessed, in particular those relating to staff immunity status and infection prevention and control.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to monitor the practice’s performance, in particular the number of patients being excepted.
  • Encourage improved uptake of national cancer screening initiatives and childhood immunisations amongst the practice population.
  • Ensure all staff complete sepsis awareness training.
  • Accurately record smoking status for patients.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 23 August 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of The Grove Surgery on 19 January 2016. A breach of legal requirements was found. After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – safe care and treatment.

From the inspection on 19 January 2016, the practice were told they must:

  • Ensure that patients’ medication is kept under review to minimise risks associated with taking medicines that require monitoring.

From the inspection on 19 January 2016, the practice were told they should:

  • Risk assess stocks of emergency medicines kept to ensure they are suitable to enable the practice to respond appropriately to a medical emergency.

We undertook a focused inspection at The Grove Surgery on 23 August 2016 to check that they had followed their plan and to confirm that they now met legal standards and requirements. This report only covers our findings in relation to those areas found to be requiring improvement. You can read the report from our last comprehensive inspection, by selecting 'all reports' link for The Grove Surgery on our website at www.cqc.org.uk

We found that on the 23 August 2016 the practice now had improved systems and we found the following key findings:

  • Practice specific protocols and procedures had been developed to manage risks to patients taking medicines that require routine monitoring.
  • Systems to ensure that patients taking these medicines were receiving appropriate and timely checks had been effectively implemented.
  • Risk assessments in relation to emergency medicines had been undertaken and appropriate stocks of emergency medicines were kept.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 19 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Grove Surgery on 19 January 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and but not always actioned, such as those relating to the monitoring of patients taking medicines that require regular monitoring.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • The practice engaged with the CCG to provide additional services to improve outcomes for patients.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

  • Ensure that patients’ medication is kept under review to minimise risks associated with taking medicines that require monitoring.

In addition the provider should:

  • Risk assess stocks of emergency medicines kept to ensure they are suitable to enable the practice to respond appropriately to a medical emergency.
  • The practice should review and extend work to improve ease of access for patients requiring a non urgent appointment, including the extension of online services.
  • Develop systems to oversee the safe management of blank prescription forms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice