• 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

During an assessment under our new approach

Date of Assessment: 01 May 2025 to 06 May 2025. Thorpe-le-Soken Surgery is a GP practice and delivers service to 7,513 under a contract held with NHS England. There is a branch surgery at Kirby Cross, patients can access services at either surgery. The practice dispenses medicines to approximately 1048 people living in the rural areas of the practice population. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the practice, the context the practice was working within and how this impacted their service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE: The service had a good learning culture and people could raise concerns. Evidence provided showed managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and risks and incidents were discussed in staff meetings. The facilities and equipment met the needs of people, and we observed they were clean and well-maintained, and any risks mitigated. There were enough staff with the right skills, qualifications and experience to meet the needs of people using the practice. We found staff had received training and regular appraisals to maintain the delivery of high-quality care. Evidence seen showed medicine was well managed and people were involved in planning any changes.

EFFECTIVE: People were involved in the assessment of their needs. Staff reviewed assessments taking into account people’s communication, personal and health care needs. Health care provision was based on latest clinical guidance, good outcome evidence, and good practice. Staff worked with stakeholders involved in people’s care and treatment for the best outcomes and smooth transitions when moving between services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those people that took decisions in people’s best interests when they did not have capacity.

WELL-LED: Leaders and staff had a shared vision and culture based on honesty openness, listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff to develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local Primary Care Network (PCN) to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

People’s experience commentary

People were positive about the quality of their care and treatment. Recent survey results, including from the National GP Patient Survey and the NHS Friends and Family Test, showed the majority of people were satisfied with services. The practice stayed connected with their patient participation group (PPG) via a Facebook group who were able to represent the views of people using the service. We spoke with 4 people using the services at the practice on the day of the site visit, they provided positive comments about the staff, clinicians, the practice environment, how they accessed the practice and the involvement in their care and treatment.

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