Thorpewood Medical Group Also known as Woodside Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that leadership and governance delivered person-centred care, supported innovation and promoted an open, fair culture. We assessed a total of 7 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.

Although leaders were visible and modelled inclusive behaviours, continued governance failings meant that the provider was unable to adequately manage performance and risks.

We found breaches of regulation for the Well-Led key question and have told the provider to take action.

This service scored 62 (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 aimed to deliver high quality care based on effective teamwork and in partnership with its active patient participation group. Leaders were committed to providing safe, effective and person-centred care whilst at the same time understanding the challenges and needs of people and their communities.

The provider had recently introduced a Practice Development Plan. Staff had contributed to the development of the plan, and we noted it included proposals to reopen the practice’s branch location.

Leaders did not always understand the context in which the service delivered care, treatment and support. Although they embodied the values of their organisation, were visible and led with honesty, they were not always knowledgeable about issues and priorities for the quality of services.

Staff told us leaders were approachable, responded to any concerns raised and modelled the values of the practice. We saw that the leadership team worked with other practices in its primary care network (of other local practices).

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns, and we saw examples where staff had used the arrangements in place to positive effect.

The provider valued diversity in their workforce. Leaders worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures to promote diversity and equality were in place. New protocols had been introduced to ensure all staff were valued (for example, a flexible working policy which allowed eligible employees to request a change to their working pattern).

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk or share this with others when appropriate.

For example, patient monitoring systems had failed to identify overdue medications reviews, act on drug safety alerts or advise patients of Controlled Drugs risks. We noted that concerns regarding Controlled Drugs monitoring had previously been identified at our 2021 inspection.

Governance systems had also failed to adequately act on or mitigate against risks associated with inadequate emergency fire lighting coverage. Records showed that these risks had been highlighted but not acted upon at maintenance inspections in 2023 and 2024.

Also, governance systems had failed to identify that the provider’s clinical supervision protocols had not been updated to reflect the recent addition of a physician associate role and to ensure they were supported to work within a safe and appropriate scope of practice.

In the above areas, we were not assured there were effective governance systems in place to manage current performance, future performance and risks.

We saw some evidence of how the practice was monitoring and taking action to improve performance (for example regarding cervical screening uptake and antibiotics prescribing).

Managers held regular practice meetings with staff, during which they discussed issues such as significant incidents and complaints. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access; and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services. For example, the district nursing team spoke positively about regular multi-disciplinary partnership meetings which supported joined-up care. Local care home staff told us that the provider was open and transparent when working to improve care.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The practice had a Practice Development Plan in place to help drive service improvements. This included a focus on refurbishment and clinical staff recruitment. All staff were encouraged to put forward and test out new ways of working. For example, a clinical leader told us that they offered Cognitive Behavioural Therapy (a type of talking therapy) for their patients as the local wating time was typically 9 -12 months.