Thurleigh Road Practice

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 Good. At this assessment, the rating remains the same.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. On the day of the site visit we reviewed 6 staff files clinical and non-clinical we also reviewed the practice staff training matrix, and all staff were up to date and had completed role specific training.

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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. We saw the practice had a clinical safety alert and incident handling procedure policy, where (clinical incidents medication errors, near misses) were reported, managed, and learned from, this was reviewed in March 2025. We were informed every incident was analysed and a significant event analysis was undertaken. Significant events were a standard agenda item during clinical meetings and all staff meetings. The practice had a duty of candour policy in place which was reviewed February 2025, leaders explained they realised the importance of being clear and transparent.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff gave examples of patients on their safeguarding register transferring from 17-18 years of age moving from child to adult services, and the support they continued to need. Other examples included diabetes pathways and working closely with the local hospital. Staff explained they also had a palliative register, and they followed these patients up carefully, they worked closely with the local hospice and made sure urgent care plans were in place.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. We saw a referral policy reviewed in February 2025, staff also informed us that urgent referrals had to be processed on the same day as the patient consultation and a spreadsheet was updated daily to keep track of all referrals.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. All staff we spoke with were aware of the safeguarding lead in the practice and how to escalate any concerns they had.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. We saw the safeguarding policy was reviewed February 2025. We spoke with the partners of the practice, and they demonstrated that they had good oversight of the current patients on both the child and adult safeguarding registers. Partners informed us safeguarding was a standard agenda item at clinical meetings and all staff meetings, there were also quarterly Multi-Disciplinary Meetings (MDTs) where registers were discussed, and electronic patient management systems were used to manage both registers.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Data from the GP Patient survey 2024 showed a total of 85% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was below the local average of 92% and national average of 91%. During this assessment we received feedback about the practice. None of the respondents gave negative feedback about their level of involvement in decisions about their care and treatment.

Emergency equipment was available and maintained well. Equipment was located in an accessible place and all staff were aware of where it was kept. The practice was large and set out over 3 floors. Staff had measured the time it took to reach equipment, in the event of needing it for a medical emergency.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. We saw all staff (clinical and non-clinical) had completed sepsis awareness training.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Medical gases, such as oxygen, was stored safely, the practice also had a defibrillator and emergency medicines which were checked weekly. The practice was owned by a former partner. Contracts were in place to ensure the premises were maintained to keep everyone safe. The maintenance and upkeep of the building internally and externally was good. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. We saw weekly fire alarms checks were done and fire drills were conducted every 6 months; a fire risk assessment was done in May 2025, all actions had been addressed, there were 3 fire wardens. A health and safety risk assessment was done in May 2025. Electrical, gas and Legionella checks had all been done in the last 12 months.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff training records we reviewed confirmed that staff were up to date with training including completing safeguarding and fire safety.

Safe recruitment practices were generally followed. We reviewed 6 staff records. Some documents required as part of the safer recruitment process were missing, however we were assured that this was an administration issue, and the documents had been checked but they were not filed. The practice manager assured us that this would be addressed immediately, and all files brought up to date.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. The schedules listed the frequency of cleaning and the areas that should be cleaned every visit for each room. We looked in 5 clinical rooms and patient / public toilets. All rooms had sufficient supplies of liquid soap and paper hand towels. The taps in clinical rooms were lever operated to avoid the risk of re-contamination. Risk assessments and audits were completed, and actions taken to mitigate risks.

Cleaning schedules were also in place for equipment such as nebulisers, blood pressure monitors and weighing scales. Staff told us any equipment used was cleaned immediately after use.

The service generally made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. For example, the monitoring of patients on high-risk drugs we found for one specific drug there were 18 records, we looked at 5 and found clinicians were not putting a specific day of the week on the prescription instructions, the impact to patients was minimal.

We also identified for medicines that required monitoring 2 patients were overdue monitoring. This was a risk as the medication has a narrow therapeutic window which could result in relapse for the patient hence the need for regular monitoring. When we raised this with the practice they confirmed they would be following up these patients, and that the patients had attended the practice the day of the assessment.

We found that the practice was effectively monitoring safety alerts for example patients prescribed Valproate had been given appropriate pregnancy prevention plans.

Medicines including controlled drugs were stored securely and at appropriate temperatures.

Daily records of the maximum and minimum vaccine fridge temperatures were recorded. Staff were aware of what to do if any fridges had temperature readings outside of the required range. All fridges were lockable to ensure only authorised staff could access them.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. There was a dedicated member of staff responsible for overseeing this task. Appropriate arrangements were in place if this person was on leave.

All Patient Specific Directions (PSDs) we looked at were in date and appropriately authorised). PSDs are used to authorise health care assistants (HCAs) to administer medicines.

All Patient Group Directions (PGDs) we looked at were in date and appropriately authorised. PGDs allow some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Safety alerts were received by the practice pharmacist and shared with the staff team. Clinical staff we spoke with confirmed that they were made aware of relevant alerts that affected them, an excel spreadsheet was kept and pharmacist would go through patient list as required.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.