Thurleigh Road Practice

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Our review of clinical records for patients with long term conditions such as asthma, chronic kidney disease and hypothyroid demonstrated that these conditions were being monitored well. Our review of monitoring patients with hypothyroidism who had not had thyroid function test monitoring for 18 months identified that out of 347 records, we looked at 4 records and found that for 1 patient there was no evidence of any action taken by the practice and for 3 patients they were overdue testing, the risk of harm was quite low. When we raised this with the practice, they informed us they would be following up and making contacting with these patients.

We saw that pathology results and clinical letters had been viewed and were up to date, however we did find 154 inbound documents some dating back to February 2025 were awaiting coding. When we raised this with the practice, they informed us that there were no concerns, and the documents had all be reviewed and cleared. The practice told us they had a zero-backlog policy, with 3 appointed administrators, the practice sent us additional information such as polices which showed they had clear processes in place.

Feedback from people using the service was generally positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community.

Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We were informed the clinician makes a referral if they felt the patient would benefit and multiple sessions were run, where the social prescriber contacts external organisations if required. This could be for housing or social help. The social prescriber comes once a week. We were told they had successful outcomes when they had signposted patients to other services.

The practice used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or where translation services were needed.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was mostly provided in line with current guidance. We did find some clinical records we looked at demonstrated care was not always provided in line with current guidance for example clinicians were not always including the day of the week when prescriptions were issued. We also found for two patients taking medicines that required monitoring they were both overdue monitoring. Staff carried out annual reviews for people with long-term conditions. For example, we discussed annual reviews of patients with diabetes with the nurses who managed diabetic patients. The nurses had completed the relevant training and had systems and processes in place for effective monitoring.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Nurses gave examples of how they worked with district nursing and mental health teams to ensure continuity of care and joint working with other services.

They had a safeguarding and multi-disciplinary team meeting with school nurses, as well as weekly clinical meetings which they all found helpful for sharing information. We were told the practice had a notice board where they display information that was relevant. They have different department heads who discuss things together.

Partners told us complex cases were discussed in multidisciplinary team meetings (MDT) meaning all staff are familiar and can hand over care. There were also registers of people with specific priority needs such as vulnerable children and people with serious mental illness.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Data from the 2024 National GP patient survey showed 64% of people completing the survey had received enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses local. This compares to 70% locally and 68% nationally Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. The practice was involved in weight management (nurses lead on this) and smoking cessation (someone from the Integrated Care Board (ICB) took led on this). In addition to this the practice had Yoga on prescription, anyone over 65 could do a class once a week. the instructor adapts exercise to their needs, to keep the elderly moving as much as they can. The practice was involved in diabetic programmes, (and during the assessment had signed up to be involved in the national diabetic audit).

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The practice had undertaken a range of audits for patients. This included vitamin B12 levels, secondary care referrals for chronic kidney disease and Vitamin D levels in adults. Although there was a range of audits, they appeared to be one cycle.

The practice met national targets for screening and immunisations. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service provided evidence of actions taken to improve the uptake of childhood immunisations. We saw unverified data which showed improvements in targets over the last 12 months. Staff told us the practice was starting to implement a more effective recall system. This included meeting with the linked Health Visitor to work together on engaging more parents and guardians in the immunisation programme as well as cervical screening uptake.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.