Thornbury Medical Practice

Updated 2 February 2024

Thornbury Medical Practice is located in Bradford at:

Rushton Avenue

Bradford

West Yorkshire

BD3 7HZ

The location was visited as part of the inspection.

The provider is registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures.

The practice is situated within the NHS West Yorkshire Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 7,150. The practice works with 9 other local GP practices in the PCN 5 primary care network.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the lowest decile (1of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 51% Asian, 42% White, 2% Black, 3% Mixed, and 2% Other.

The age distribution of the practice population mirrors the local average. However, there are significantly less patients aged 45 and above than the national average and more patients aged 44 and below. There are more male patients registered at the practice compared to females.

There is a team of 2 GP partners (both male), and 2 long-term locum GPs (1 female, 1 male). There is a practice nurse, 2 long-term locum nurses, a physician associate, a long-term locum advanced clinical practitioner and 2 healthcare assistants. There is a practice manager, assistant practice manager, 2 office managers and 7 reception staff.

The practice is open between 8am to 6pm Monday to Friday, and has extended hours opening between 7am and 8am on Thursdays.

The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally through a federation and PCN working where late evening and weekend appointments are available. Out of hours services are provided by Local Care Direct Limited.

Updated 2 February 2024

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 6 September 2023. The overall rating for the practice was inadequate, and the service was placed into special measures. Warning notices were subsequently served on the provider for breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulations 16 Receiving and acting on complaints, Regulation 17 Good governance, and Regulation 19 Fit and proper persons employed. The full report of this comprehensive inspection can be found by selecting the “all reports” link for Thornbury Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was an announced focused inspection carried out on 19 January 2024 to check that the provider had responded to the warning notices dated 8 September 2023, and met the legal requirements in relation to the breaches of Regulation 16, Regulation 17, and Regulation 19. The provider was required to be compliant with the matters documented in the warning notices by 22 December 2023.

This report covers our findings in relation to those requirements. The inspection has not resulted in any new rating and the practice remains rated as inadequate and in special measures.

How we carried out the inspection/review

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 remotely and during a short on-site visit.

• Reviewing records to clarify actions taken by the provider.

• Requesting and reviewing information from the provider.

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 the provider.

We found that:

• The provider had made the required improvements in the areas identified in the warning notices.
• The provider had systems and processes in place to ensure that staff work histories, including gaps in employment, had been recorded. Systems and processes were also in place to ensure that professional qualifications were assessed and copies of these held, and that professional registration checks for clinicians had been carried out.
• The provider had established and implemented a system for identifying, receiving, recording, and handling complaints. Actions taken by the provider included updating the complaints policy and complaints leaflet. We saw that complaints had been responded to in a timely manner, and that learning from complaints had been shared with staff and used for service improvement.
• We saw that essential policies and procedures had been reviewed and updated, and carried accurate information. This included the whistleblowing policy, training policy, and the clinical governance policy.
• The system to authorise practitioners to administer certain medicines had been reviewed, and we saw documentation which showed that such staff had been properly authorised.
• The provider had appointed a Freedom to Speak Up Guardian to provide support to staff who wanted to raise concerns. Staff we spoke with told us that they felt able to raise concerns with the leaders and managers at the practice, and were aware of the newly appointed Freedom to Speak Up Guardian.
• The provider had established and implemented a new system for managing significant events and incidents. We saw that when identified, these had been investigated, and that any learning had been shared with staff at team meetings, and used to improve services.
• The provider had implemented new systems and processes to monitor and manage staff training. We saw that staff training was up to date.
• The provider had reviewed and updated information given to locum GPs and agency staff to allow them to carry out their duties. This included information about safeguarding and referrals.
• We saw that meetings were minuted, and that these minutes were detailed and contained sufficient information to guide those staff who had not been able to attend the meetings.

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

• Upload the updated complaints policy and complaints leaflet to their practice website.

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