The Care Quality Commission
  • Doctor
  • GP practice

Thorpe-le-Soken Surgery

Overall: Good read more about inspection ratings

The Surgery, High Street, Thorpe-le-Soken, Essex, CO16 0EA (01255) 861850

Provided and run by:
Thorpe-le-Soken Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Thorpe-le-Soken Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Thorpe-le-Soken Surgery, you can give feedback on this service.

05 August 2022

During a routine inspection

We carried out an announced inspection at Thorpe-le-Soken Surgery on Friday 05 August 2022. Overall, the practice is rated as Good.

Safe – Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Following our previous inspection on 01 December 2015, the practice was rated Good overall and for safe, effective, caring, and responsive key questions and Outstanding for Well-led:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Thorpe Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. This was a comprehensive inspection that included:

  • Inspection of the key questions:
  • Safe
  • Effective
  • Caring
  • Responsive
  • Well-led

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • Staff questionnaires.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

  • Patients with safeguarding identified had been discussed in safeguarding meetings and alerts attached to patient’s records.
  • Health and safety, risk management systems including fire, the dispensary, and medicines management processes, were well managed.
  • Although we found no concerns with infection control an audit had not been undertaken for over two years and this included hand washing audits.
  • We found nine patients taking one of the high-risk medicines had not received one part of the expected monitoring. Six patients taking medicine for hypothyroidism had not received a blood test check for 18 months, and three of the five diabetic patients we reviewed had not received a face to face review or diabetic retinopathy screening in the last 18 months. Immediately actions were taken on our findings by the practice to ensure patients received this monitoring. At the on-site visit we were shown how their new protocol was working however, this process needed to be monitored and embedded.
  • We found some patients had a potential missed diagnosis of diabetes and chronic kidney disease. The practice took immediate action and changed their monitoring process to ensure this did not happen in the future.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice respected patients’ privacy and dignity, and patient confidentiality was maintained throughout the practice
  • The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic, they had increased infection control cleaning processes and replaced flooring and seating.
  • The practice was led and managed to promote the delivery of high-quality, person-centred care.

We found a breach of the regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Continue to encourage patients to attend for cervical cancer screening.
  • Continue to encourage patients aged five to receive two doses of measles, mumps and rubella vaccination.
  • Continue to encourage patients to participate in a patient participation group (PPG).
  • Continue to improve access to the practice via the telephone.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

01 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thorpe Surgery on 01 December 2015. Overall the practice is rated as good. Specifically, we found the practice was good for safe, effective, caring and responsive services, and outstanding for well-led, services. The effects of these ratings apply to everyone using the practice, including all the population groups.

Our key findings across all the areas we inspected were as follows:

  • Staff knew how and where to raise concerns and report safety incidents and near misses. The practice used all opportunities to learn from internal and external incidents to improve service quality.

  • The practice used excellent communication to work with other local healthcare providers to improve their patient outcomes.

  • Feedback obtained from patients about their care was consistently and strongly positive in both the responsiveness and caring aspects of their care and treatment.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from the patients in their patient participation group. For example access to practice services had been improved by extending opening hours and reviewing when appointments are available.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available in the practice, on their website and was easy to understand.
  • The practice had a statement of purpose which had safe, effective, responsive care as its top priorities.

We saw an area of outstanding practice :

  • The clinical leadership and management team were fully committed to a systematic approach to work with patients and local healthcare providers. The practice matron role was developed to create collaborative links with both social care and clinical care organisations. The practice matrons were responsible for implementing the practice approach to Avoiding Unplanned Admissions’ and visited patients identified as in need of frequent or recurrent care, whether this was in their own homes or residential care. The matrons communication weekly with; social services, district nurses, community matrons, palliative care, end of life teams, the practice GP care advisor and other community agencies was to share information and coordinate care for these identified patients. This information was documented and discussed weekly with the practice clinical team to ensure care and treatment was understood for these patients and the team could be proactive with their care to improve quality of life. When the practice population doubled after taking over another practices branch surgery they, recruited a salaried GP, increased their nursing staff and further developed the practice matron roles to take on certain previous GP responsibilities that would free-up their existing GPs to ensure patient care in their local area was not compromised.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice