Thornton Lodge 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We saw that there was a defined governance and management structure in place, and that this had been regularly reviewed and updated. Staff informed us that they were aware how to raise concerns, and felt that these would be actioned. The provider recognised the importance of engaging with their local community and had put in measures to achieve this, though they recognised that this would be a long-term commitment. However, we also noted that some staffing checks required improvement, this included assurances regarding staff vaccination status and Disclosure and Barring service checks.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality, diversity and inclusion, engagement, and an understanding of the challenges and needs of their local community. Whilst some staff were unclear on the specific vision of the service, all staff we spoke with showed a clear desire to provide the best treatment and care to their practice population. All levels within the practice had a good understanding of the challenges faced in the delivery of the vision, and aims of the provider. For example, they recognised both cultural and language issues and the need to support and guide their patients to better achieve improved health outcomes for them. Key to much of this activity was the work that had been undertaken to engage with local communities, and the need to break down barriers to the take up of activities such as participation in the national child immunisation and cervical screening programmes. Many staff within the practice were multi-lingual and this helped with overall engagement, and the ability to deliver effective non-clinical services and clinical care.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Staff told us leaders in the practice were approachable, supportive and friendly. Many staff mentioned the family-like feel of working in the practice, and how well staff helped each other. Leaders told us that on occasion staff had been asked to work from other nearby practices when capacity demanded. They admitted that this at times was unpopular. Staff told us that they felt able to raise concerns with managers. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area. We found practice leaders to be frank and transparent with us regarding past contractual issues, and how these had been addressed.

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, and whilst all staff were not aware of who specific contacts were, they knew the processes in place to raise specific concerns. We heard from the provider how concerns had been raised with them when staff had been asked to work across sites to both increase capacity and to learn new skills such as supporting people with the recently adopted online booking tool. They explained how they had tried to work with staff to reduce these concerns. To support the provider’s freedom to speak up approach a whistleblowing process had been developed, and this was available to staff on their shared computer drive. On a less formal basis, leaders and managers told us that they had an open-door policy and welcomed direct contacts from staff when they had concerns, issues, or suggestions to improve the operation of the practice. Staff confirmed that they generally worked well together and felt they could approach managers.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote equality, diversity, and inclusion were in place. This included, polices relating to lone working, bullying and harassment, and zero tolerance. These were available on the shared computer drive. Staff had the opportunity to engage with leaders and managers and bi-monthly meetings, and were able to raise their views and opinions via in-house staff surveys. A recent survey of 10 staff showed overall satisfaction, though it was noted that 2 staff felt that they did not have the tools to do a great job. Managers shared with us examples when staff had made suggestions which had been actioned, this included the provision of a water cooler and new seating. The provider sought to improve staff wellbeing and morale through the provision of lunches at team training events, and the organisation of social events such as a staff Christmas dinner, and bowling.

The service had clear responsibilities, roles, systems of accountability and overall had good governance practices in place. They used these to manage and deliver sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider had a central management team for the practices it operated, which included Thornton Lodge Surgery. This provided management support for key core services, which included finance and human resources. Staff told us they had clear responsibilities, and were aware of management structures. Staff had access to all required policies and procedures on the shared computer drive or in hard copy. Managers held regular bi-monthly practice meetings with staff, during which they discussed non-clinical and clinical developments and emerging risks. Senior managers and clinical staff also attended monthly clinical governance meetings. The provider used a dedicated electronic platform for managing operations across the practices it operated. It allowed effective data and information transfer, supported regulatory compliance with reminders for audits and risk assessments, and supported the tracking of allocated tasks, demand and capacity planning, and resource allocation. However, we also noted that some staffing checks required improvement, this included assurances regarding staff vaccination status and Disclosure and Barring service checks.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked with other practices within their primary care network, and through this joint working patients were able to access extended access services at nearby practices. We saw that staff attended monthly safeguarding and palliative care meetings to discuss and manage some of their most vulnerable patients. For example, we heard from the provider how they proactively worked with local health visitors to raise child immunisation participation. The provider had developed a close working relationship with community and religious organisations. For example, the provider told us how they had worked closely with a local community group to raise the awareness of, and participation in, the national cervical screening programme. The provider had reestablished a Patient Participation Group (PPG), although they acknowledged that membership and attendance was limited. We spoke with a member of the PPG, and they informed us that whilst the group was still in its forming phase, they hoped that their views would be listened to and acted upon, and felt that their own involvement would have a positive impact on the service.

The service focused on continuous learning, innovation and improvement across the organisation, and the local health 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 provider had quality improvement activities in place within the practice to help drive improvements in services. This included clinical audits, joint working with community partners to improve the take up of cervical screening amongst the practice population, and provided active support for patients in how to use the newly adopted online system for appointment booking. Activity in this latter area saw 1,600 additional patients signing up to use the online system. We also heard how the provider planned to work with local community groups to support diabetic patients through Ramadan. We saw that following our assessment that the provider had examined areas for improvement, and had identified learning. For example, the provider had identified the need to improve long-term condition recalls and monitoring up take, they wanted to examine whether it may be more appropriate to directly book a follow-up appointment with the patient at the time of the original consultation, rather than relying on the patient to do this at a later date. Quality improvement activity including clinical audit findings were regularly discussed at monthly clinical governance meetings. These meetings were minuted and available to all staff on the shared practice computer drive.