Thornton Lodge Surgery

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• 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 found that the provider requires improvement for the delivery of safe care and treatment to patients. We saw that measures were in place which protected people from abuse and avoidable harm. For example, we saw that the premises had necessary health and safety measures in place. However, there were areas which required improvement. These included, the need to tackle a processing backlog of medical records for incoming patients, gaining assurance that staff were suitable for employment in their appointed roles, such as confirmation that they had the necessary immunisation and vaccination status, and had undergone appropriate Disclosure and Barring Service checks, and ensuring that patients in receipt of prescribed medicines had received the required health monitoring or review. This is the first inspection for this service since its registration with CQC. This key question has been rated as Requires Improvement. The service was in breach of legal regulations in relation to Regulation 12(1) Health and Social Care Act (Regulated Activities) Regulations 2014 Safe care and treatment. This breach related to the failure of the provider to have full vaccination status of staff in line with guidance, that all staff had not received Disclosure and Barring Service checks appropriate to their role, a backlog in the processing of incoming medical records, and a failure to deliver care support for asthma patients.

This service scored 56 (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. Learning opportunities such as significant events and complaints were discussed at monthly clinical governance meetings. These meetings were minuted, and were available to staff on the shared computer drive. Incidents and concerns were also discussed at bi-monthly team meetings. As an example, we saw how the provider had identified and investigated a significant event regarding a prescribing error, and had put in place measures to prevent a recurrence. The provider had processes for staff to report incidents, near misses and safety events, and there was a system to record and investigate complaints. In general, the provider tried to deal with verbal complaints immediately in-house. More complex complaints, or those classed as formal complaints, were investigated and responded to by a centralised team which covered other practices operated by the provider. However, we heard from a patient of an instance when a formal complaint raised with the practice around 2 years previously had not been responded to. When we discussed this with the provider, they told us that they had no record of the formal complaint having been received, and told us that they would investigate this further. We examined responses to 3 complaints in detail, and found these to be detailed and contained information about how to escalate a complaint further should the patient be dissatisfied with the response. At the time of this assessment the provider told us that no complaints were being dealt with by the Parliamentary and Health Services Ombudsman. The provider had systems in place for clinical audit and clinical supervision, both of which supported learning and service improvement.

The service did not always establish and maintain safe systems of care, including when people moved between different services. The provider had a significant backlog of information relating to new patients which required processing. At the time of inspection there was a summarising backlog of 1,002 records. The provider told us that they had lost their staff member who summarised records in 2022 and had been unable to fill this vacancy. In partial mitigation of the risk this posed to patient safety, the provider obtained directly from patients essential information via their new patient registration form. This identified key information such as allergies and currently prescribed medication. The provider told us that whilst they did not have dedicated summarising staff at present, they were in active discussions with local locum summarisers to support the clearance of the backlog. Notwithstanding this summarising issue, we saw that the provider worked with other health professionals to deliver shared care, and monitored and supported patients when they moved between services. For example, we saw that processes were in place to manage test results in a timely manner, and that patients referred via the 2-week cancer referral pathway had the referral progress monitored. The provider also had other processes in place to assess and support patients who had been discharged from hospital, or who required changes to their medication following secondary care treatment.

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, whilst protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We saw that the service shared concerns quickly and appropriately. The provider had appointed senior health professionals to function as leads and deputies for child and adult safeguarding. Safeguarding policies were in place and known to staff, and staff had been appropriately trained in safeguarding, and understood their duties including how to raise concerns regarding domestic violence and female genital mutilation should this be identified. The practice computer system was used to identify vulnerable patients and their family members. The computer system also allowed the sharing of information with other health and care providers, and therefore supported improved joint working and understanding. The practice maintained a list of vulnerable people, and acted on concerns working in partnership with other organisations. Staff from the practice met regularly with other health and care professionals to discuss vulnerable patients and their families. The provider offered chaperones to patients who requested them, and we saw that staff who acted as chaperones had been trained to deliver this activity.

The service worked with people to understand and manage risks. They worked with patients and provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The practice provided care to a diverse community which had a high prevalence of conditions such as diabetes and smoking. We saw evidence how they had worked with local community leaders and groups to improve health and care outcomes for patients. For example, they had undertaken community awareness events to raise cervical screening uptake, and had engaged with parents who were reticent to put forward their child for key vaccinations. Many staff had the language skills which enabled them to speak with patients in their own preferred language, and if required had access to translation and interpretation support, which allowed them to involve themselves in their care and treatment, and to manage any associated risks. Emergency equipment and medicines were available within the practice building, and we saw that these were regularly checked 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. However, a patient fed back to us that they felt communication with the provider concerning their care had been limited and needed improvement.

The service worked to identify and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had management processes in place which gave assurance that health, safety and wellbeing requirements were met. For example, health and safety and Control of Substances Hazardous to Health risk assessments had been undertaken and shared with appropriate staff. Fire risks were managed, and we saw evidence that regular fire alarm checks and fire evacuation drills had been carried out. The practice premises was overall in a safe condition, although it was noted that the paving slabs at the entrance to the practice were uneven, and the infill between the slabs was missing and posed a trip hazard. From checks of records, and observations made on the day of our visit, we saw that equipment had been maintained, and when required had been tested and calibrated to ensure safe and effective operation. The provider had developed a business continuity plan, and if required services could be delivered at other local practices operated by the provider.

The service did not always ensure that on appointment, checks had been made regarding staff, their suitability for their roles, this included carrying out Disclosure and Barring Service checks to the appropriate level, and gaining assurances regarding staff immunisation status. They had not always made sure that staff received effective support, and development. Leaders told us that staffing levels were monitored, and rotas were in place which ensured that there was the right mix of staff numbers and skills in place. The provider used a digital management platform to have oversight of demand and capacity across the service. For example, they reviewed workload levels, incoming correspondence and test result activity, and urgent service demands. If workload pressures were excessive, this was escalated to their provider’s central team to plan and source the additional resources required. As the practice was located close to others operated by the provider, there was the opportunity to move staff between locations when extra capacity was needed. The majority of staff felt that staffing levels were sufficient, although we received some comments that additional clinical cover could improve appointment availability. We found that staff were working within their agreed areas of competence, and that clinical supervision processes were in place for clinical staff. We saw that training was generally up to date for staff. However, we found that 1 staff member had not received a recent appraisal, when issues such as training needs could be discussed. Furthermore, effective recruitment practices were not fully in place. The provider had only limited assurance of the vaccination status of staff in line with current guidance. In addition, in 1 case a member of the clinical team had only received a standard Disclosure and Barring Service check, rather than an enhanced check. The provider confirmed that the latter issue would be rectified immediately.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading, and knew when to share concerns with appropriate agencies. The practice had a designated infection, prevention and control lead, and all staff had received training in infection prevention and control suitable to their role. We saw that the practice premises was clean, although it was noted that minor areas and furnishings and fitments required repair. For example, seating in the waiting area was torn, and there was a damaged area of wall plaster in the nurse’s room. Waste storage including clinical and general waste was well managed, and there was a clinical waste contract removal contract in place. Externally, we saw that the practice was subject to fly-tipping, and we were told by the provider that this needed to be removed on a regular basis at cost to the provider. Cleaning schedules and supporting risk assessments were in place and followed. Prior to the assessment visit we had been informed that on occasion materials such as cleaning products were in short supply. However, at the time of our visit the cleaner’s cupboard was well stocked and well organised, and that other materials including personal protective equipment levels were satisfactory. We saw evidence that both internal and external infection prevention and control audits had been carried out. These were detailed and included areas for improvement, which we saw the provider had either acted upon or planned to action. The provider had only limited assurance of the vaccination status of staff in line with current guidance, and only had full assurance in 4 out of 6 records we checked.

The service did not always make sure that ongoing medicines management processes were safe and met people’s needs. We saw evidence that staff involved people in reviews of their medicines and conditions. Staff received regular training, were assessed on medicines prescribing, and prescription stationery appropriately managed. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people in general received the required timely medicines reviews and monitoring. Medicines and vaccines kept in the practice were stored securely and at appropriate temperatures, although it was noted that the 2 storage refrigerators did not have secondary temperature monitoring devices fitted. We saw staff regularly checked the stock levels and expiry dates for all medicines held. The provider had in place measures to effectively manage medicines and patient safety alerts. Our remote clinical searches showed that staff overall followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, we noted that of 194 patients prescribed ACE inhibitors or Angiotensin II receptor blockers, 5 had not had the required monitoring, although we saw that they had recently been invited to attend. In addition, when we looked at 5 patients who had been over prescribed asthma inhalers, we saw that 2 of these patients were overdue their asthma review. When we discussed this with the provider, they told us that they had some patients who were non-compliant with requests to attend reviews and monitoring, and used techniques such as prescribing shorter duration amounts of medicines to prompt attendance. Since the assessment we have been informed that reviews had either been undertaken for patients, or that further recalls contacts made with patients. We saw that completed medicines reviews were detailed. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.