Thorpewood Medical Group Also known as Woodside Surgery

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.

We assessed a total of 8 quality statements from this key question. At our last inspection we rated this key question as Requires Improvement. At this assessment, the rating remains the same.

The service did not always ensure staff received effective clinical supervision. The service did not always ensure that medicines and treatments were safe. The provider had not fully acted on successive, previously identified fire risks or on patient monitoring concerns identified at our last inspection. Lessons were learnt to continually identify and embed good practice. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

This service scored 59 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. 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. A senior doctor led significant incidents analyses and we saw processes for staff to report incidents, near misses and safety events. When things went wrong, staff apologised and gave people support. Staff gave examples of where learning from incidents had resulted in changes that improved care for others. For example, after incorrect paper notes were given to a patient, enhanced identification checks were introduced.

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.

There were systems in place for processing information relating to new patients. Local care homes spoke positively about how the service worked with other providers when patients moved between services. People spoke positively about how referrals and test results were managed in a timely way.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this objective. 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 provider shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The provider 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.

Emergency equipment was available and maintained. 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.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. However, records highlighted a failure to fully act on concerns about adequate coverage of fire emergency escape lighting, identified during maintenance inspections carried out in 2023 and 2024.

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.

The service did not always ensure clinical staff received safe clinical supervision. We looked at supervision arrangements concerning a recently created Physician Associate role. Physician associates are healthcare professionals who provide medical care as part of a multidisciplinary team. They must always work under the supervision of doctors.

Although we were saw that the post holder worked under the direction of a named senior doctor, clinical supervision protocols had not been updated to incorporate the new role, support the post holder and ensure they worked to a safe and formally agreed scope of practice. Consequently, we saw that the provider’s scope of practice allowed the post holder to treat children with minor illnesses, pregnant women with minor illnesses and some patients experiencing poor mental health. We noted this was contrary to Royal College of General Practitioners (RCGP) guidance which recommends a very specific Physician Associate scope of practice. When we highlighted our concern, the provider took immediate action to amend protocols and ensure the post holder worked within a scope of practice that was in accordance with RCGP guidance.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date; and that learning needs and development of staff were appropriately managed. We saw that generally, safe recruitment practices were followed.

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 received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks (including regarding a bacterium called Legionella which can proliferate in building hot and cold water systems).

The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found that the provider did not always have an effective system to manage and respond to drug safety alerts. For example, the practice had not acted on a Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update which recommended enhanced monitoring where patients were taking combinations of heart failure medicines. Our remote clinical searches highlighted that potentially 15 of 48 patients taking combinations of heart failure medication were overdue the recommended 6 monthly monitoring. When this was highlighted, the provider took immediate action to arrange appointments with these patients.

We found that Controlled Drugs monitoring arrangements did not always reflect National Institute for Health and Care Excellence (NICE) best practice guidance; specifically, an absence of consistent advice on the addictive potential of these medicines and or if steps were being taken to reduce the dose. For example, 4 out of 5 records reviewed highlighted the absence of any attempt to wean patients and 2 out of 5 additionally highlighted an absence of advice on addiction risks. We noted that concerns regarding Controlled Drugs monitoring arrangements had been highlighted at our 2021 inspection.

We found that Disease-modifying antirheumatic drugs (DMARDs) monitoring arrangements did not always reflect NICE best practice guidance. DMARDs are immunosuppressive and/or immunomodulatory drugs designed to influence the course of a disease and NICE guidance recommends that people taking DMARDs receive regular monitoring due to the risk of adverse effects such as pulmonary toxicity and increased risk of infection. Our remote clinical searches highlighted that 25 patients were being prescribed a DMARD called Azathioprine. NICE recommends monitoring patients on Azathioprine for toxicity including monitoring full blood count and liver function tests at least every 3 months. However, when we reviewed five patient records, we noted that one patient had recently been prescribed Azathioprine in February 2025 but that their last Full Blood Count, Urea and Electrolytes and Liver function test had last been recorded in November 2023.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. For example, leaders were aware that antibiotic and hypnotic prescribing were above local and national averages and pointed to recent clinical audits which had reduced prescribing levels. Leaders also told us that they had also sought to reduce the number of telephone consultations (as it was more difficult to assess the need for antibiotics during this type of consultation).