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 requires improvement because there was a lack of governance regarding medicines management. 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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice was no longer in breach of regulation 17 (good governance) because they had developed more robust systems and processes to monitor medicines effectively. They had established governance processes that were appropriate for their service to deliver good quality, sustainable care, treatment and support. The practice had clear responsibilities, roles and systems of accountability. The provider acted on up-to-date information about risk, performance and outcomes, and shared this securely with other services, when appropriate.

Managers met with staff regularly and completed annual appraisals. Staff were given opportunities to progress within their role if this was of interest to them. Both team and multidisciplinary meetings were held on a regular basis where clinical concerns and emerging risks were discussed. The minutes were shared with staff to ensure this information, including actions was acknowledged and adhered to. Policies and procedures were accessible on a shared system and were reviewed accordingly. We saw evidence of clinical audits that reflected improvements to patient care. Staff took patient confidentiality and information security seriously.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.