Thorneloe Lodge Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement due to the lack of effective processes and systems in place for monitoring and reviewing high-risk medicines putting patients at risk.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a shared vision, strategy, and culture. This was based on transparency, equality, diversity and inclusion, engagement, and understanding the challenges and needs of people and their communities. Additionally, the practice promoted a positive, compassionate, listening culture that supported trust and understanding between staff and patients using the service whilst focusing on learning and improvement. Staff expressed how the practice was a happy, friendly and supportive place to work. They shared a common aim to do the best they could for patients and strived to provide safe, high-quality, and compassionate care. Leaders told us they encouraged staff to make suggestions to enhance the vision, values and strategy. For example, a suggestions box was available for staff to use and open discussions were held in wider team meetings.

The practice had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us that leaders in the practice were visible, approachable and responded to any concerns raised. Staff explained how the leaders had listened to their feedback and some shared examples where changes had been made. Staff also told us leaders modelled the values of the practice. We saw the leadership team were engaged in the development of primary care services within the local area.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns and felt confident they would be dealt with appropriately.

The practice had systems and policies in place to promote equality and diversity in their workforce. They worked towards an inclusive and fair culture. Staff had completed equality and diversity training. Staff feedback about the culture of the practice in the context of workforce equality was positive. Leaders made reasonable adjustments to support staff to carry out their roles well.

Staff told us they were clear about their responsibilities, roles, systems of accountability. Staff had access to policies and procedures and knew who to talk to if they had concerns or questions. Managers met with staff to complete appraisals and performance reviews. Clinical concerns were discussed during team meetings and the minutes were shared to ensure the relevant information and actions to take was acknowledged and addressed. Our clinical records review identified that not all systems and processes for medicines management and long-term conditions were operating effectively. For example, some patients taking high risk medicines (methotrexate and lithium) were not monitored and reviewed in line with best practice. Not all patients prescribed these medicines received the necessary blood tests as part of their monitoring, putting patients at risk. For those patients that were reviewed, the review notes were very minimal with no detail or commentary about what had been reviewed. The prescribers were not checking whether a patient had been reviewed before prescribing the medication again.

Systems and processes were also not effective when acting upon Medicines and Healthcare Products Regulatory Agency (MHRA) alerts as not all patients were informed about the risks when taking this medication.

There also lacked good governance when considering potential missed diagnosis of stage 3-5 chronic kidney disease (CKD) as our clinical record searches identified a total of 250 patients in this search. We reviewed a random sample of 5 patients and found that 3 out of 5 patients had a missed CKD diagnosis. This puts these patients at risk of not having the appropriate medication prescribed and support to help manage their diagnosis. The practice was responsive to these findings and have contacted the necessary patients.

The practice understood their duty to collaborate and work in partnership to support care provision, service development and continuous care. The practice worked in partnership with other practices within their primary care network to offer services such as physiotherapy, wellbeing coaches, microsuction and overflow GP telephone and face to face consultations. Staff and leaders engaged with people, communitiesand partners to share learning with each other and to promote continuous improvement. Working alongside practices in the primary care network, enabled the practice to identifynew or innovative ideas that could lead to better outcomes for people.

The practice focused on continuous learning, innovation and improvement across the service. Leaders encouraged staff to develop creative ways of working to improve the quality of life for people.

The practice had a quality improvement plan in place to help drive improvements. Staff participated in quality improvement work and used learning from significant events and complaints to continually improve the service they provided. Leaders were enthusiastic about their patient triage model operated in the practice. Staff explained they felt their patient triage model was innovative and effective as they had a clinician sitting in the reception area with staff to oversee phone calls and be on hand to answer any questions.

The practice was a well-established training practice offering experience to students, including an apprenticeship scheme. Systems were in place to support trainees during their placements. Staff were offered opportunities to develop and take on more senior roles within the practice if this was of interest to them. Staff were supported to develop their skills around improvement and innovation. The appropriate training was given to enable this. Staff talked positively about their experiences of joining the practice, moving to new roles and the ongoing support and development.