The Grove Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence the practice was led effectively and in a way that was inclusive, supported improvement and innovation and made sure patients received care that was safe and effective.

At our last inspection we rated this key question good.

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

Leaders and staff did not always demonstrate a shared vision and culture based on listening, learning and trust. Staff understood their roles and responsibilities but did not always feel supported to give feedback or raise concerns. Following the inspection, the practice told us they had appointed a Freedom to Speak Up Guardian. While leaders were accessible to staff, the leadership team was not always working in a coordinated manner, which sometimes led to variation in communication. This meant that opportunities for shared learning and improvement were not always maximised. Engagement with external partners and the wider community was taking place.

This service scored 46 (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 have a clear shared vision, strategy and culture. Staff understood the challenges and the needs of people and their communities.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

While staff shared a common aim to provide the best possible care for people, and described strong, supportive working relationships within the team, staff also told us they had not been involved in the development of the vision or future plans for the practice. Some staff told us they did not feel there was a clear vision for the future of the practice. Following the assessment, the provider described actions taken to improve staff engagement, including the use of meetings and additional mechanisms for staff to share feedback.

The practice did not have any formal plan, strategy, vision, mission statement or set of organisational values. There was also limited evidence of effective succession planning to support continuity and sustainability of leadership.

Staff and leaders were aware of some challenges affecting the service, including the limited space available and more patients registering with the service. However, the practice had not always taken steps to address them safely and effectively. For example, staff had raised concerns about one of the clinical rooms but there was no evidence that this had been recorded or addressed.

There was a lack of strategic leadership and ineffective oversight of the day-to-day running of the practice. This meant risks affecting the service were not identified and managed. This included gaps relating to checks of infection prevention and control (IPC), checks to make sure emergency medicines and equipment were always available and safe to use, incomplete actions following fire safety risk assessments, checks related to medicines management to ensure medicines were used safely and securely, and checks of staff records including training and development.

Leaders had also not carried out their statutory responsibilities to notify other organisations about certain situations or events affecting the practice. These included informing CQC about an incident involving the police.

Staff feedback about leadership was mixed. Although leaders and managers were generally visible and approachable, not all staff felt leadership was open or transparent. Some staff felt their concerns and ideas were listened to, while others felt unable to raise concerns openly. Staff also described a lack of consistent working between members of the leadership team, which resulted in differing approaches and made the working environment more challenging.

We observed that the leadership team collaborated effectively with other practices within the Primary Care Network (PCN).

Staff did not always feel they could speak up and that their voice would be heard.

Staff who provided feedback for this inspection told us they knew what whistleblowing was. However, not all staff were aware of the practice’s whistleblowing policy, and only a small number of staff had completed training on whistleblowing.

Staff said they could approach a specific member of practice staff for support, including to raise concerns with the practice’s leaders and managers. However, confidence in doing so varied. Some staff told us they felt able to raise concerns, while others said they did not believe these would be acted upon. A small number of staff described situations where they felt comfortable raising certain issues but not others, depending on the nature of the concern.

We also heard feedback that, in some parts of the team, speaking up was not always encouraged between colleagues, which contributed to inconsistent confidence in raising concerns.

The practice did not have a Freedom to Speak Up (FTSU) Guardian or any arrangements with someone from outside the practice for staff to raise concerns if they felt they needed external support or advice. No staff had undertaken any training on FTSU.

The practice valued diversity in their workforce. There was a mixture of staff from various ethnic backgrounds. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

We saw adjustments had been made to ensure staff were valued, for example accommodating requests to change working hours had been made to support staff who were carers.

Most staff told us they felt valued and treated fairly. Staff gave examples of the practice supporting them with professional development and career progression. However, some staff said there were fewer opportunities to develop and progress, and other staff told us that leaders did not always recognise good performance, which they felt would help to increase confidence.

The practice had robust, fair and transparent recruitment policies and procedures. An equality and diversity policy was in place, and staff had completed equality and diversity training.

Leaders and all staff we spoke with were clear on their individual roles and responsibilities, however some staff told us they did not have enough time to carry out some of the tasks given to them, for example to check medicines and equipment. Some staff also told us they had not had additional training to ensure they could complete these tasks safely and effectively.

Managers met with staff to complete annual appraisals and performance reviews. However, the practice did not have effective oversight of staff training. Although the practice used an online training system that allowed them to monitor some training, there were still large gaps in training records for all staff. For training that was not available online, the practice did not have an effective system to monitor completion. This meant they were unable to identify what training staff had completed, what training was still needed, and when refresher training was due.

While clinical staff described an open-door culture where they could approach the duty doctor, or any available clinician, for support and advice when needed, the practice did not have a formal system in place to make sure staff worked in line with the practice’s policies, national guidelines and within their competencies. For example, through structured clinical supervision or running audits or searches on the clinical records system to review practice.

The practice had not identified when there were gaps in recruitment checks or knowledge of staff immunity to certain infectious diseases, so that any risks to patients and staff could be managed effectively. This was particularly the case for locum and agency staff.

The practice had governance processes that were appropriate for their service. Staff could access all required policies and procedures, and managers held regular practice meetings with staff, where they discussed practice information, clinical concerns and emerging risks, and learning from events. Managers clearly recorded any actions arising from these meetings and ensured they were shared with staff. Staff took patient confidentiality and information security seriously.

However, these governance processes did not consistently provide effective oversight or assurance and were not used effectively to identify gaps in training, monitor compliance, or manage risks to patients and staff.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. There were some examples where they worked together for improvement.

There was an active patient participation group (PPG) that represented the views of the people using the practice. Staff told us patient feedback was collected through the PPG. There was information on the practice’s website and in the waiting area about how the PPG supported the practice and how people could join the group.

The practice worked closely with their PCN, and there was a wide range of staff from the PCN who supported the practice’s work. The service was actively involved in PCN initiatives, such as the carers’ coffee morning.

However, partnership working was not consistent across all organisations. One external partner agency told us the practice did not always engage effectively with them.

The practice did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was some quality assurance work. For example, medicines audits and medicines safety searches were carried out by PCN staff, who reported their findings to the practice. The practice also gave an example of a service‑evaluation audit they had carried out on the process for managing urine sample collection. A process change was introduced and the audit reported some improvement as a result.

Staff told us they were supported when they undertook courses for their learning and development. Learning needs were identified through annual appraisal processes. Staff could request learning opportunities, and support was provided when training was undertaken. However, this did not always take account of workload pressures. In one example, a staff member undertaking a course did not have their role backfilled and continued to manage their usual responsibilities alongside their training.