Thorneloe Lodge Surgery

Date of Assessment: 25 June 2026 to 30 June 2026. Thorneloe Lodge Surgery is a GP practice and delivers service to approximately 11,700 patients under a contract held with NHS England. The National General Practice Profiles states that the practice population is 91.9% White, 4.2% Asian, 1.1% Black, 2.0% Mixed and 0.9% Other Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7th decile (7of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

During their previous assessment in May 2025, this provider was in breach of regulation 17, good governance, because we identified not all medicine management systems and processes were operating effectively. This assessment was focused on reviewing the breach and the quality statements that were previously rated requires improvement. During this assessment, the provider had made improvements and was no longer in breach of regulation 17, and all key questions were rated good.

People provided positive feedback about the quality of their care and treatment they received. There was an active Patient Participation Group (PPG) who represented the views of people using the service. Feedback gathered through CQC’s ‘Give Feedback on Care’ process was also positive. For example, people told us they felt staff were professional, they felt listened to, and described staff as attentive and compassionate.

Date of Assessment: 12 May 2025 to 14 May 2025. Thorneloe Lodge Surgery is a GP practice and delivers service to approximately 12,000 patients under a contract held with NHS England. The National General Practice Profiles states the practice population is 91.8% are white, 4.18% Asian, 1.06% black, 2.00% mixed and 0.86% other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 7 decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

The provider is registered with the Care Quality Commission to provide the following regulated activities; diagnostic and screening procedures, maternity and midwifery services, family planning, surgical procedures and treatment of disease, disorder or injury. We assessed all five key questions to establish if the services provided are safe, effective, caring, responsive and well-led.Since the onsite assessment, there has been updated National GP Patient Survey data released and the scores for the practice have improved overall.

The practice had a good learning culture and patients could raise concerns. The facilities and equipment met the needs of people and were clean and well-maintained to mitigate any risks. People were treated with kindness and compassion. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. There was a culture of continuous improvement.

However, we found breaches of regulation in relation to regulation 17, good governance. Our clinical records review identified not all systems and processes for medicines management were operating effectively. We have asked the provider for an action plan in response to the concerns found at this assessment.Since the onsite assessment, the practice has started to implement necessary enhancements such as drug interaction reviews, expanded pharmacy led audit cycles and improved high-risk monitoring protocols to improve patient care.