The Care Quality Commission
  • Doctor
  • GP practice

Grove Surgery

Overall: Good read more about inspection ratings

Grove Lane, Thetford, Norfolk, IP24 2HY (01842) 752285

Provided and run by:
Grove Surgery

All Inspections

20 December 2023

During an inspection looking at part of the service

We carried out a targeted assessment of Grove Surgery on 20 December 2023 without a site visit. Overall, the practice is rated as good. We rated the key question of responsive as requires improvement.

Safe -good

Effective – good

Caring - good

Responsive - requires improvement

Well led – good

Following our previous inspection in February 2022, the practice was rated good overall and for all key questions. At this inspection, we rated the practice requires improvement for providing responsive services.

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

Why we carried out this inspection

We carried out this inspection as part of our GP responsive assessment

  • Responsive question inspected

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 found that:

  • Changes to access were improving with the employment of a patient services manager to drive and monitor the changes.
  • We found that patients' individual needs and preferences were central to the delivery of services.
  • Patients could not always access care and treatment in a timely way based on feedback.
  • Although the practice had seen improved patient feedback, this had not yet been reflected in the National GP patient survey.

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 Health Care

25 February 2022

During a routine inspection

We carried out an announced comprehensive inspection at Grove Medical on 25 February 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection in October 2017, the practice was rated good overall and requires improvement for providing caring services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection. We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • 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-centre care.

We found examples of outstanding practice:

  • The practice offered pagers to patients who were hard of hearing which vibrated to alert them to attend their appointment.
  • Eight members of staff had enrolled on and were in the process of completing a sign language course. On the trained staff members’ lanyards, their names were displayed in sign language so patients were made aware that sign language could be used.

Whilst we found no breaches of regulations, the provider should:

  • Consider ways to encourage interactions with the Patient Participation Group.
  • Manage the backlog of summarising of patient records.
  • Assess the risk relating to the lack of availability of paediatric defibrillator pads.

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

16 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Grove Surgery on 16 August 2017. 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 a system in place for reporting and recording significant events. Events were discussed with those involved in the significant event.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • The practice held monthly multidisciplinary team meetings to discuss safeguarding.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • The practice performance for the Quality and Outcomes Framework scores was above local and national averages.
  • The practice uptake for cervical screening was lower than local and national averages.

  • Patients we spoke with told us they were treated with care, dignity and respect.

  • The results of the GP patient survey, published in July 2017, were lower than local and national averages for several aspects of care. However, the practice had a clear action plan in place to address this, including a practice specific survey.

  • The practice had a bereavement process which included the review of recently bereaved patients and their families in multidisciplinary team meetings.

  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. The practice discussed complaints in clinical meetings.

  • Patients we spoke with said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. Translation services were also available.

  • 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 the requirements of the duty of candour; we saw evidence which showed the practice complied with these requirements.

The areas where the provider should make improvements are:

  • Continue to act on and ensure improvement to national GP patient survey results to improve patient satisfaction.

  • Continue to encourage patients to attend appointments for all cancer screening. 

  • Review the practice process relating to exception reporting of patients with a long term condition to ensure all patients are followed up.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Grove Surgery on 3 March 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 well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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.

We saw areas of outstanding practice:

  • GPs provided where appropriate, home visits for patients requiring end of life care at weekends and bank holidays. GPs each had a GP buddy for peer review and support. In addition GPs provided support to each other, nursing and admin staff through daily meetings to review care and treatment. This had led to better outcomes for patients, particularly those in receipt of palliative care.

  • Further to patient demand appointments with all GPs and nurses were extended to 15 minutes per appointment.

  • The practice information technology team attended local schools to speak with sixth form students about health services available in the area, and oversaw the practice social media pages. The practice posted information such as opening times, practice news, recruitment, health news and up coming open days and meetings.

  • The practice’s uptake for the cervical screening programme was 89%, which was above the CCG average of 77% and the national average of 81%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test. The practice demonstrated how they encouraged uptake of the screening programme by using information in different languages. Patients with a learning disability were given bespoke support to attend. A female sample taker was made available for patients.

The areas where the provider should make improvement are:

Ensure patients waiting for their appointments in all areas of the practice can be clearly seen by reception staff to ensure patients whose health might deteriorate can be seen by staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice