The Care Quality Commission
  • Doctor
  • GP practice

The Grange Surgery

Overall: Good read more about inspection ratings

The Causeway, Petersfield, Hampshire, GU31 4JR (01730) 267722

Provided and run by:
The Grange Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Grange Surgery on 6 July 2023. 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 Grange Surgery, you can give feedback on this service.

01 December 2020

During a routine inspection

We carried out an announced comprehensive inspection at The Grange Surgery on 1 December 2020 to review the actions taken by the practice to improve the quality of care provided since the previous inspection in October 2019. We rated this service as Good overall.

At the previous inspection published on 30 December 2019, the practice was rated as inadequate overall with a rating of inadequate for providing safe and well led services. The practice was rated as good for providing effective, caring and responsive services. As a result of the concerns identified, we issued a warning notice for breach of Regulation 17 Good Governance and a requirement notice for Regulation 19 Fit and Proper Persons employed. The practice was placed into special measures. We carried out an announced follow up inspection on 15 January 2020 and found that the practice had met the legal requirements in relation to the warning notice.

In light of the Covid-19 pandemic, CQC has looked at ways to fulfil our regulatory obligations, respond to risk and reduce the burden placed on practices by minimising the time spent on site in the service, during the pandemic, when compared to a traditional inspection. Due to this, we based our judgement of the quality of care at this service on a combination of:

  • information the practice sent to us before the inspection
  • remote staff interviews between 19 November and 24 November 2020
  • 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 good for providing safe, effective, caring, responsive and well led services and for the following population groups: older people; people with long-term conditions; families children and young people; people whose circumstances may make them vulnerable and people experiencing poor mental health (including dementia).

We found that:

  • Risk assessments had been carried out and actions had been completed in a timely manner to keep patients and staff safe.
  • Infection control audits had been completed in line with practice policy and actions to mitigate risk had been carried out.
  • The practice had implemented a log of safety alerts and updated this accordingly to ensure actions had been completed.
  • The practice had introduced a new system to record significant events and complaints which were discussed at practice meetings and outcomes and learning identified was recorded and shared with staff.
  • The practice made improvements to its recruitment system to ensure newly employed staff had a disclosure and barring system (DBS) check or appropriate risk assessment in place.
  • The practice had implemented a new process to ensure that all clinical staff registration was monitored and up to date.
  • Staff vaccinations were maintained in line with Public Health England guidance.
  • The practice had made improvements to its oversight of monitoring of staff training.
  • The practice had reviewed and updated their systems and processes to ensure compliance with practice policies and national guidance.
  • Practice policies were fully embedded, appropriately reviewed and accessible to staff.
  • 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. Patients could access care and treatment in a timely way.

The areas where the provider should make improvements are:

  • Continue to monitor the system for recording fridge temperatures to ensure this is carried out on a daily basis.
  • Continue to review and address areas of improvement identified through staff feedback.
  • Continue to improve uptake of cervical screening to meet the 80% national target.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

15 January 2020

During an inspection looking at part of the service

Previously we carried out an announced comprehensive inspection at The Grange Surgery on 16 October 2019.

We served a warning notice to the provider following a breach of regulation 17, Good Governance, of the Health and Social Care Act 2008. We also issued a requirement notice in relation to regulation 19, Fit and Proper Persons Employed.

We carried out an announced focused follow-up inspection at The Grange Surgery on 15 January 2020 to confirm that the practice had met the legal requirements in relation to the warning notice served after our previous inspection in October 2019. This report covers our findings in relation to the warning notice only. This means the ratings from our inspection in October 2019 remain the same until a further comprehensive inspection is undertaken.

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.

At this inspection we found that the requirements of the warning notice had been met in relation to Regulation 17, Good Governance.

We found that:

  • There were improvements in systems and processes including significant events, safety alerts, legionella, fire safety and infection control.
  • Actions from risk assessments and audits had been completed in a timely way
  • Risk assessments had been appropriately completed to keep patients and staff safe.
  • Improved governance systems were in place which included a meeting structure with standard agendas and up to date policies which had been reviewed and appropriately stored.
  • Staff training including GP training was complete and up to date.

The areas where the provider must make improvements continue to be:

  • Ensure that fit and proper persons are employed.

The full report published on 30 December 2019 should be read in conjunction with this report. The practice remains rated as inadequate until a full comprehensive inspection is carried out by the Care Quality Commission.

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

Rosie BenneyworthChief Inspector of General Practice BM BS BMedSci MRCGP

16 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Grange Surgery on 9 October 2018 as part of our inspection programme and found breaches of regulations and the practice was rated as requires improvement. This inspection on 16 October 2019 was an announced comprehensive inspection to follow up on breaches of regulation and as part of our inspection schedule where services rated as requires improvement are subject to re-inspection within 12 months.

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
  • Caring
  • Responsive
  • 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 inadequate overall and in safe and well-led. They are rated good for effective, caring and responsive and good for all the population groups with the exception of working age people which is rated as requires improvement.

We rated the practice as inadequate for providing safe services because:

  • Risk assessments and actions to mitigate risks were not carried out in a timely way.
  • Infection control audits had not been regularly completed and action to address risks had not been carried out.
  • There was no system for recording and acting on safety alerts.
  • The system for learning and improving when things went wrong was not comprehensive.
  • Disclosure and Barring Service (DBS) checks were not undertaken when required.
  • There was not a system in place to monitor the ongoing registration of clinical staff.
  • Staff vaccinations were not monitored in line with Public Health England guidance.
  • GPs had not all undertaken safeguarding training updates.

We rated the practice as inadequate for providing well-led services because:

  • Governance systems were operating ineffectively.
  • Arrangements for managing and mitigating risks were inconsistent.

We rated the practice as good for providing effective services because:

  • Patients received
  • effective care and treatment that met their needs.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as good for providing responsive services because:

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure that fit and proper persons are employed.

The provider should:

  • Review the process for the identification of carers within the practice with a view to increasing the proportion of carers identified.
  • Include information for patients on escalating concerns to the ombudsman when responding to complaints.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

09/10/2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous rating July 2015 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at The Grange Surgery on 9 October 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The completion and recording of training by staff was not fully embedded at the practice.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The practice participated in pilots and health promotion schemes to encourage patients to be proactive in monitoring their own health needs.
  • The practice was adjusting to a new clinical arrangement following several recent retirements within the senior clinical team.
  • The practice encouraged feedback and there was evidence to show the practice had acted upon it, especially with regards to patient feedback.
  • There was limited evidence to show that themes were being identified by the practice in relation to complaints.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Patients were positive about the care and treatment they received at the practice.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.


The areas where the provider should make improvements are:

  • Continue to improve the uptake for cervical screening to achieve the national target of 80%.
  • Review how the practice records staff vaccination status.
  • Review how the practice identifies themes from complaints.
  • Review how the practice acts upon formal feedback provided by staff.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

8th July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Grange Surgery on 8 July 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice also set up and ran a Health Zone confidential drop in service for young people age 12 to 19 years of age on Wednesdays during term time from 2.30pm to 4.30pm
  • The practice had amended the clinic times for older patients to fit in with new bus timetables which operated in the surrounding villages.
  • Patients who attended for dressing changes were routinely screened for other health and social needs whilst their dressings were changed.
  • On occasion reception staff had ensured that medicines had been delivered to housebound patients.
  • 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice