Thorneloe Lodge Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as requires improvement because not all medicine management systems and processes were operating effectively. At this assessment, improvements had been made and the rating had changed to good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand and manage risks by considering people’s overall needs and circumstances. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff were trained in basic life support, and how to recognise a deteriorating patient and knew what action to take. . Patients were advised on risks related to their condition and actions to take if their condition deteriorated. 87% of respondents to the National GP Patient Survey felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was slightly lower than the local average of 93% and national average of 92%.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

As part of our assessment, a series of patient clinical record searches were carried out by a CQC GP specialist advisor. This assessed whether clinicians were prescribing a range of medicines safely and whether they reviewed patients who were prescribed medicines which required monitoring.

We reviewed patients prescribed Azathioprine (an immune system suppressant drug) which required regular monitoring. We identified 18 patients prescribed this medication and all were monitored in line with best practice. We also reviewed patients prescribed direct oral coagulant (DOAC) medicine used to prevent blood clots. We identified 439 patients prescribed DOAC. Out of these patients, 13 were potentially overdue their monitoring. We reviewed a random sample of 5 patients and found that 2 patients had not received the appropriate blood test monitoring. In response to our feedback, the practice provided us with evidence that a blood test appointment had been booked and attended.

There was a process in place for recording and sharing Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts. Our clinical record search reviewed patients prescribed Aldosterone Antagonists (a medicine used to block the effects of a hormone produced by the adrenal glands) with ACE inhibitors or ARBs (a medicine used to lower blood pressure). Most patients had received the appropriate monitoring.

We identified a total of 683 medication reviews that had been completed for patients in last 3 months. We reviewed a random sample of 5 medication reviews and found that all of these reviews were completed appropriately with detail in the patient record.

The practice adhered to an antibiotic stewardship policy that measures the appropriate use of antibiotics and optimises the use of antibiotics to improve patient outcomes.

Staff regularly checked emergency equipment including emergency medicines. Medical gases such as oxygen were stored safely.