Grovehill Medical Centre

We carried out an announced comprehensive inspection at Grovehill Medical Centre on 15 December 2022. Overall, the practice is rated as good.

The key questions are rated as:

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection of Grovehill Medical Centre under the registered provider Dr Parminder Singh who became the provider from November 2020.

We had inspected the practice under the previous provider’s registration on 31 August 2016 and the practice was rated as good overall. However, the practice was rated as requires improvement for being well-led. A follow up focused inspection on 17 May 2017, rated the practice as good for well-led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Grovehill Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

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.

We have rated the practice as Requires Improvement for providing safe services because:

The practice’s systems, practices and processes to keep people safe and safeguarded from harm were not always effective. For example:

• The practice’s systems to monitor and record all staff mandatory training were not effective.
• Not all staff were up-to-date with the practice’s mandatory training requirements, such as in safeguarding and infection prevention and control.
• The practice’s system for reviewing and recording staff recruitment checks required improvement.
• Leaders had identified that improvements were needed to the practice’s system for the reviewing and recording of Disclosure and Barring Service (DBS) checks for staff, where required.
• Developments were needed to the practice’s system for the monitoring and recording of staff vaccination compliance and for risk assessing non-clinical staff to identify vaccination relevant to their role, as per UK Health Security Agency (HSA) guidance.

We also 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.
• Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We found one breach of regulations. The provider must:

• 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)

In addition, the provider should:

• Continue to take actions to improve cervical screening uptake.
• Continue to make arrangements to keep all staff up-to-date with the practice’s appraisal requirements and develop systems in place to monitor and record staff appraisals.
• Develop staff access to the Freedom to Speak Up Guardian for the practice.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services