The Grove 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

This means we looked for evidence there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good.

At this inspection, the rating has changed to requires improvement.

The service did not always have a good learning culture and people could not always raise concerns. Managers investigated incidents. People were protected and kept safe. Staff understood and managed risks, however, processes for managing risk required strengthening.

The facilities and equipment were clean and generally met the needs of people, but we identified areas where they were not well‑maintained. Infection prevention and control audits were not fully completed, and the actions from these had not been embedded to mitigate any risks identified.

Managers did not always make sure staff were up-to-date or received training relevant to their roles. Staff we spoke with understood risk, however, processes for managing risk required strengthening. Medicines management was not always effective and stronger governance processes were required for safe care.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not always have 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 identified and used to support improvement and embed good practice.

Some people told us they felt supported to raise concerns and staff treated them with compassion and understanding. However, some people also told us they did not know how to raise a concern and did not feel confident their concerns would be addressed. Representatives from the patient participation group (PPG) told us they felt the practice took concerns seriously and proactively made improvements to the service.

Some staff told us they did not always feel encouraged to raise concerns and felt the culture was not always open when things went wrong. Even so, safety was seen as a priority and the practice had systems in place to support reporting. The practice had processes to record incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

Learning from incidents, clinical issues and complaints was shared through staff meetings, and some actions taken as a result led to changes that improved care.

The practice worked with people and healthcare partners, including the primary care network (PCN), to establish and maintain safe systems of care. This helped make sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. Staff told us they had the information needed to deliver safe care and treatment. Referrals and test results were managed in a timely way. Staff involved in making referrals were clear about their roles. Checks were in place to ensure referral requests had been actioned. For example, there were effective processes for oversight and tracking of referrals, including urgent referrals for suspected cancer.

The practice worked with people and healthcare partners to understand what being safe meant to them. There was a safeguarding lead, and safeguarding policies were in place and known to staff. Safeguarding was a standing agenda item at clinical meetings.

Staff told us they were confident in reporting concerns and understood the process for raising them. Staff gave examples of how they supported vulnerable people, including those who had missed appointments. We reviewed the staff safeguarding training matrix provided by the practice and found that a third of staff members had not completed or were not up-to-date with the required adult or child safeguarding training relevant to their roles.

The practice maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations. Arrangements were in place to follow up vulnerable people who did not attend their appointments, including secondary care appointments.

The practice did not always consistently involve people in managing risks associated with their care.

Emergency equipment was not readily available or maintained. It was stored in a way that was not easily accessible and was difficult to transport quickly in an emergency. Some recommended resuscitation equipment and emergency medicines were not available, and there was no evidence that the practice had undertaken a local risk assessment for this. There was no effective process in place for checking the equipment and emergency medicines. We found expired items, including paediatric pads for the defibrillator and some emergency medicines.

Following our assessment, the practice had informed us that replacements for the expired stock had been ordered. We did not see evidence that expired items had been replaced, and concerns about equipment accessibility remained. This meant we were not assured that emergency equipment was readily available or safe to use in an emergency.

Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities, and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been carried out, however, not all identified risks had been addressed. Appropriate testing of electrical equipment had been completed. The practice was unable to show evidence that the gas boilers had been serviced. Following our assessment, the practice sent us evidence that these risks had been addressed, including confirmation that the gas boiler service had been arranged.

Staff had completed fire safety training and there were named fire marshals for the practice, however not all staff were aware of the fire evacuation plans.

Control of Substances Hazardous to Health (COSHH) risk assessments were available for products used by cleaning staff. However, there was no COSHH signage or clear identification of cleaning products, and we found expired cleaning items. The practice responded to our feedback and told us that expired stock had been removed and replaced.

We had concerns about the safety of one of the clinic rooms which was being used for a range of clinical activity, including blood tests, minor procedures such as dressings, diagnostic tests (for example ECGs and Doppler checks) and learning disability reviews. Some of these activities carry an increased risk of people becoming unwell or distressed. Due to the size and configuration of the room, it was not adequately safe given the nature of its use.

Staff told us that concerns had been raised previously but no action had been taken. There was no evidence of a risk assessment for this room at the time of the inspection. The practice responded to our feedback by providing additional storage elsewhere to improve the space and outlining a longer‑term plan to restructure the room. Shortly after our inspection, the practice informed us that the room had since been risk assessed and that they were liaising with relevant stakeholders in relation to the longer-term limitations.

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

The practice mostly made sure there were enough staff to provide safe care, and operated effectively when fully staffed. However, there were no effective arrangements in place to provide cover when staff who had specific roles and tasks in the practice were absent.

There were a range of clinical and non‑clinical roles within the practice. Staff had received annual appraisals; however, we found that most staff were not up-to-date with all the essential training required for their roles.

Clinical staff undertaking training programmes were receiving some supervision. However, there was no formal system of supervision in place for staff, particularly those who were not enrolled on a training course. In response to our feedback, leaders told us of their plans to introduce more formal supervision for their clinical staff.

The practice had a recruitment policy and followed safe recruitment processes for permanent staff. Leaders had ensured that Disclosure and Barring Service (DBS) checks were completed for staff prior to starting their employment. However, the practice could not give assurance that all locum or bank staff had been appropriately recruited, trained and supervised.

Staff worked well together to provide safe care that met people’s needs, and staff worked within their areas of competence.

The practice did not assess or manage the risk of infection effectively. They did not always detect and control the risk of infection spreading or share concerns with the appropriate agencies promptly.

The practice had an infection prevention and control (IPC) policy and a designated IPC lead, and most staff knew who this was. However, the lead had not received additional training required to support them in this role.

Most staff had completed the required IPC training, and staff had responsibility for following safe IPC practices relevant to their roles. However, when asked about systems in place for safely dealing with clinical specimens and spilled bodily fluids, staff demonstrated limited understanding. This meant it was unclear whether the training had been effective, as not all staff were able to explain what to do in the event of a spillage.

Although some IPC audits had been carried out, they were not embedded, and overall oversight of IPC was limited. Cleaning schedules were in place but not being followed routinely. Cleaning records were not being kept up-to-date. We found expired IPC equipment, including hand sanitiser, wipes and spillage kits. Sharps boxes were incorrectly labelled, and temporary closures were not being used.

These findings indicated that IPC systems were not being effectively monitored or implemented to ensure risks were identified and managed. The practice responded to our feedback by confirming that expired stock had been removed and replaced, that staff and cleaners had been reminded of requirements, and that monthly IPC checks would now take place, however, these actions have not yet been embedded.

Staff immunisation records were not consistently complete, and the practice did not have a full immunisation history for some newly appointed staff.

The practice did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their care, including when changes happened.

The practice did not demonstrate effective systems to ensure that blank prescription stationery was maintained and stored securely to prevent unauthorised access or use.

Checks of medicines requiring refrigeration were not consistently documented. Records showed gaps in fridge temperature monitoring. Although no temperatures recorded were outside the acceptable range, the practice did not demonstrate adequate oversight of this area.

Some staff were authorised to administer certain medicines under Patient Group Directions (PGDs), such as flu vaccines. PGDs must be authorised and signed by the appropriate person before staff work under them. Although all PGDs we reviewed were in date, the practice did not have sufficient oversight of the authorisation process. We found names had been added to the authorised staff list after the PGD had been signed. This meant some staff were administering medicines under a PGD without proper authorisation.

Staff involved people in reviews of their medicines and helped them understand how to manage their treatment safely. People knew what to do and who to contact if their condition did not improve or if they experienced unexpected symptoms. Staff followed protocols to ensure medicines were prescribed safely. They ensured people received the recommended medicines reviews and appropriate monitoring.

Staff followed established processes to ensure people prescribed medicines with specific risks received the required checks. During our search of the practice’s clinical system, we reviewed patients prescribed methotrexate, a high‑risk medicine requiring regular blood tests, and found all monitoring to be appropriate and up-to-date.

We also reviewed 5 records for people prescribed DOACs, a medicine used to prevent blood clots, and found that in all cases, appropriate monitoring and dosing checks had been completed.

Staff took steps to prescribe medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, prescribing levels of gabapentinoids and hypnotic medicines were in line with local and national averages.

The practice had processes in place for monitoring patients’ health in relation to medicines and for handling repeat prescription requests. Our searches of the clinical system showed that 372 medicines reviews had been completed in the 3 months before our inspection. We reviewed 5 records and found all reviews had been completed appropriately.

The practice had effective systems to manage and respond to safety alerts and medicine recalls. During our search of the clinical system, we reviewed 5 people prescribed topiramate (a medicine used to treat seizures or migraines), where an alert required that women of childbearing age must be informed of the risk of harm in pregnancy. In 2 cases where this was relevant, the associated risks had been discussed and documented.