- GP practice
Thorneloe Lodge Surgery
Assessment report published 22 July 2025
Contents
Ratings
Our view of the service
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.
People's experience of this service
The practice encouraged and used feedback from people who used the service to make improvements. Both verbal and written complaints were investigated and used to drive improvement. Although feedback from the National GP Patient Survey was mixed, scoring slightly lower than the national average, people who used the service were also invited to provide feedback directly to CQC. We reviewed this feedback, and patients gave positive responses regarding their overall satisfaction. The practice conducted their own internal survey. The results showed that patients felt positive about their overall experience of the service; patients felt listened to, treated with care and concern, involved in decisions about their care and treatment, and had confidence and trust in the healthcare professionals. There was an active Patient Participation Group (PPG) that represented the views of people using the service. They felt engaged with the practice and listened too.