Thornton Lodge Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure their patient’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was mostly positive. For example, 94% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last GP appointment compared to both local average of 91% and a national average of 92%. In addition, 96% of patients felt the healthcare professional had all the information they needed about them during their last appointment, which as above the local and national averages of 92%.

We saw that the provider was highly aware of the social and cultural needs of patients, and had measures to support this, such as employing staff who had local language skills and the ability to access translation and interpretation services if these were required to support effective needs assessment. Patients that had additional needs had these identified clearly on their patient record, which allowed staff to make adjustments when required.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them

Systems were in place to share updates and changes to guidance with staff. This included discussion at clinical meetings and via direct communication with staff. Examination of staff records showed that mandatory training and role specific training and updates had been undertaken.

Our remote clinical searches showed mixed performance with providing care in line with guidance and best practice. For example, only 5 of 109 patients with hypothyroidism (an underactive thyroid) were overdue monitoring, and we saw that these patients had been regularly recalled, but had not attended. In addition, 100% of patients with advanced chronic kidney disease had been monitored.

However, our searches also identified that aspects of asthma care needed improvement with 1 of 5 patients on their asthma register, and in receipt of steroid medication had not been issued with a steroid card. We also identified concerns regarding the recording, assessment and subsequent prescribing of antibiotics and steroids for patients following an acute exacerbation. In addition, it was noted during our remote searches of patient records that some patients who had been identified as pre-diabetic had not had this noted on the patient’s active problems list with their record, although we saw that they were subject to regular recalls for monitoring. We later received assurance that these patients had pre-diabetes added to their records.

The provider worked well across teams and services to support people. Apart from a noted issue regarding the processing of incoming patient records we saw that staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. They made sure that patients only needed to tell their story once by sharing information effectively when they moved between services. Staff worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, the surgery had embedded staff from their local Primary Care Network to support their medicines optimisation and management.

We saw that the provider had in place processes to ensure the monitoring of referrals to other services such as 2-week wait cancer referrals. In addition, to assess the quality of these referrals, they had been subject to clinical audit which showed high levels of compliance.

The provider met regularly with multidisciplinary colleagues including community and palliative care nurses, health visitors and safeguarding teams to discuss vulnerable patients or those with complex needs.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Patients with caring responsibilities were supported, and information, advice and services such as flu vaccinations were available to them at the surgery. We heard that a community carers event had been held at a nearby surgery operated by the provider which was open to patients from Thornton Lodge Surgery. There was also carers information available within the surgery.

Staff had been trained in Care Navigation which enabled them to better assess patient need, and where appropriate refer of signpost them to services. For example, patients could be referred to other care services including social prescribers and wellbeing coaches as well as wider public health providers to support weight management and stopping smoking. In addition, the provider participated in the Community Pharmacy Consultation Service, which supported patients to access direct care and advice.

The surgery offered a range of health checks including NHS health checks. Data showed that of 381 patients eligible for a health check in the last 12 months, 72 had been completed.

We saw that the provider was committed to supporting, encouraging and enabling their patients to live healthier lives. We heard how they had recognised the challenges they faced regarding local health issues such as diabetes, smoking and a lack of participation in public health programmes, and had put in place measures to tackle these. For example, the surgery supported asthma awareness, flu vaccination, weight management, and smoking cessation through dedicated health promotion and patient engagement sessions. In addition, in February 2026 the surgery held a Ramadan healthy eating session to provide culturally appropriate health and wellbeing advice to patients who were observing Ramadan. This included advice on maintaining a balanced diet, portion awareness and the importance of hydration.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The provider had embedded invitation and recall procedures in place for monitoring, reviewing and screening patients. They had recently commenced the utilisation of a clinical workflow and management platform to automate and streamline processes. We were informed the system will be used to strengthen the management of patient recalls, long-term condition monitoring, medication reviews, blood tests, and follow-up care. As part of the implementation process for this new system clinicians and administrative staff were to be trained to ensure it was used consistently and effectively.

Performance for a number of health programmes was below that expected. In 2024 cervical screening attainment was only 47.2% for 25 to 49 year olds, and 68.8% for 50 to 64 year olds. The surgery provided us with unverified/unpublished data for performance from April to July 2026 which indicated a combined in year cervical cancer screening attainment of 52.1%. Participation in bowel and breast cancer screening was 48.9% for bowel screening against a national average of 71.8%, and 38.2% for breast screening against a national average of 70.4%. To raise participation in the cervical screening and other cancer prevention programmes the provider had held a series of awareness raising sessions within the surgery and with partners in the community. Community Champions had also attended the surgery and held informal conversations with patients, enabling them to raise concerns and to discuss barriers to participating in screening. Patients were able to discuss these issues in a familiar place and with people who could speak with them in their own preferred language. This work complimented the surgery’s own recall processes. Managers reported that feedback on these sessions had been positive and it was hoped to raise patient engagement with those programmes.

Childhood immunisations were below the recommended minimum levels of 90% in 4 out of 5 indicators. For example, only 73.2% of children aged 5 had received immunisations for measles, mumps, and rubella (01/04/2024 to 31/03/2025). To tackle this lower than average performance we saw that the surgery had participated in a targeted local child immunisation improvement programme aimed at children who were overdue or who had missed routine immunisations. Child patient records were reviewed and parents and carers contacted and invited to bring in children for immunisations, this included dedicated Saturday clinics. Managers sent us unverified/unpublished data for performance from April to July 2026 which indicated a combined in year child immunisation performance of 67.4%.

At our last assessment we saw that the provider had only undertaken 2 learning disability health review of 20 patients on their register. During this assessment we saw that performance had shown some improvement, and we found that of 18 patients on their current register 6 had received a review for 2026/27, with 12 awaiting a review, of which only 4 were due by birth month. Managers told us that it would keep this performance under review.

The provider told patients about their rights around consent and respected these when delivering person-centred care and treatment.

As part of our assessment, we spoke with clinical and non-clinical staff, and they all had a good understanding of consent and its practical application. Considerations regarding consent were also given when providing care to children and young people, as was the need to assess the mental capacity of patients to give consent. We saw that staff had received appropriate training in the requirements of mental capacity legislation and best practice principles.

During our CQC remote clinical searches and our onsite visit we examined 3 patient records, and saw that ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment – a document which holds personalised recommendations for a person's clinical care in an emergency), which included decisions related to Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were both accessible to staff, and had been completed in line with relevant legislation.