Thornbury Medical Practice

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

Overall, we found that the practice provided safe care and treatment for patients. Following the inspection of the service in September 2023 when the provider was rated inadequate for safe services we saw that they had made significant improvements which included improving the guidance for locum staff, developing a safeguarding register, improving fire safety and health and safety processes including training, and ensuring staff had received relevant safety training. This assessment showed that improvements made had been embedded. However, we identified that there were still some minor areas for improvement, this included tackling the historic summarising backlog, ensuring that patients felt involved in their care and treatment, making sure patient safety advice and information was given to patients in a timely way, and the need to discuss end of life decisions with all palliative care patients.

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.

We saw no indication of concern in this area.

Leaders at the practice told us that they had established processes to improve services based on learning, as well as patients this included concerns and incidents raised by staff. This included learning from significant events, complaints, audit findings, and other feedback. Staff we spoke with, or received feedback from, confirmed that they knew how to identify and report significant events and incidents, and that these had subsequently been investigated and actions taken as a result. They said that they felt free to raise concerns with leaders and managers. Staff confirmed that they were also aware how to record and handle patient complaints. They told us that, if possible, they would attempt to resolve complaints immediately, but if this was not possible, that they would be formally recorded and actioned. We were informed by staff that learning events were standing items on monthly team meetings where these were discussed. As an example of learning we were informed of an incident when a patient had been prescribed a new dosage of medicine by secondary care. However, their old dosage had not been removed from their repeat prescription and as a result both were issued. This was recognised and the patient contacted. This led to learning regarding checking changes to repeat prescriptions.

The provider had developed and put in place policies for both complaints and significant events and incidents. These were available to staff on the shared information access platform at the practice. This platform was also used to record complaints and significant events. The provider had appointed senior staff members to lead on complaints and significant events. For example, the practice manager was responsible for the overall handling of complaints. We saw that processes were in place to share learning, and that such incidences were discussed at monthly team meetings. Minutes were available of these meetings for those unable to attend on the day.

We saw no indication of concern in this area.

Leaders, managers and staff told us that they worked with others to develop and maintain safe and responsive systems of care for patients. They told us continuity of care was important to them as they recognised that this better supported care. For example, whenever possible the provider used 2 regular locums who frequently worked at the practice. They told us that they worked with other partners to plan and deliver care to their most vulnerable patients such as those who had safeguarding concerns and palliative care patients. The provider regularly held review meetings for such patients. However, we were informed that at times attendance by partner organisations was limited. The provider told us that they had measures in place to monitor and manage patient care when they moved between services such as after referral to secondary care, admission to hospital and discharge. For example, 2 week wait cancer referrals were kept open and monitored and were only closed when the patient had attended their appointment. Staff we received feedback from were aware of referral processes, and their roles within the referral process. We saw that the number of new cancer cases treated resulting from an urgent cancer referral using latest data from 31 March 2022 was 83.3%, this was above the local average of 59.4% and the national average of 54.9%.

We received positive feedback from the NHS West Yorkshire Integrated Care Board regarding steps the practice had taken in respect to improving care and treatment.

The provider had established detailed processes for managing pathways and transitions of patients through care and treatment. At the last inspection of the practice, it was found that locums were not provided with information to support and guide them on how to undertake tasks such as referrals to secondary care and safeguarding. We saw during this assessment that the locum pack had been updated to give information on safeguarding and referrals. The provider had recently subscribed to a new integrated clinical platform to support early diagnosis and tracking of patients for fast-track care. This was in the process of being rolled out across the practice. Processes were in place to deal with incoming correspondence, and this was subject to period oversight to check on correct clinical coding. It was though noted that the practice had a historic summarising backlog of 1,203 records (reduced from 1,249). This had been recognised by the provider and an action plan developed to tackle this within 12 months. To mitigate the impact of this backlog new patient questionnaires were used to identify patients with health risks, and the paper records were held so as to be able to be accessed if required. Other clinical correspondence and test results were up to date. Individual care records, which included clinical data, were written and managed securely, and key partners had access to the shared clinical system used by the practice. There was a documented approach to the management of test results, and we saw that this work had been effectively managed by the practice.

We saw no indication of concern in this area.

We heard from leaders, and saw evidence to support this, that systems, processes and practices had been developed and implemented by the provider to ensure that patients were safeguarded. The provider told us that they ensured that Disclosure and Barring checks had been undertaken for all practice staff including locums and agency workers. Staff we spoke with were clear on how to recognise and raise a safeguarding concern. Staff told us that they had received safeguarding training appropriate to their role and this was corroborated when we checked staff training records. We heard from leaders that safeguarding meetings were held. However, on occasion stakeholder attendance was limited. These meetings were minuted by the practice, but these were not shared with stakeholders who had not been able to attend.

We received feedback from the NHS West Yorkshire Integrated Care Board regarding steps the practice had taken to improving care and treatment.

The provider had established processes to identify, record and action safeguarding concerns. This included the development of safeguarding policies and procedures, and the establishment of safeguarding meetings. Both children’s and adult’s safeguarding policies had recently been reviewed in December 2023. Following the previous inspection of the practice in 2023 the provider had developed a safeguarding register which recorded patients and their families who were vulnerable. Staff utilised icons on the clinical system to further identify at risk or vulnerable patients. Staff training, and support materials for locums ensured those working in the practice knew how to handle safeguarding concerns. The provider had nominated a safeguarding lead and deputy to oversee and manage safeguarding. Staff had received equality training, learning disability and autism awareness, and when required training in mental capacity and the Deprivation of Liberty Safeguards.

Patient feedback via the National GP Patient Survey indicated that patient satisfaction with their involvement in their own care was below local and national averages. For example, in the 2023 results only 75.9% of patients said at their last GP appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was below the local average of 86.8% and the national average of 90.3%.

We heard from leaders, managers and staff that as part of the care and treatment they worked with patients to help them understand and manage risks so that their needs were better met. They discussed, as part of our examination of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) and ReSPECT decisions, how they worked with patients, and when required their carers so they achieved the outcomes they wanted whilst understanding their options and risks associated with these decisions. It was noted that the practice had 16 patients on their palliative care register. Of these 7 had not had a DNACPR completed for them. We were told that staff from the practice worked with other care and health professionals to review and deliver appropriate patient care and treatment. Staff told us they were experienced in the completion of advanced care planning and were aware of referral routes and signposting to complimentary support and wellbeing services. When patients were referred, we were told by staff that they monitored these until the referral and been accepted, or for more serious referrals that appointments had been concluded. Staff informed us that on some occasions attendance from other external partners at joint meetings to discuss patients was limited, but that patients were still reviewed. Staff informed us that they were aware of emergency procedures within the practice, and were confident dealing with patients who were upset, anxious or emotional.

The provider had processes in place to involve people to manage risks. For example, we saw that medicines reviews were effectively conducted and carried necessary detail. In addition, patients whose treatment was subject to some risks (including risks notified to the provider via patient safety alerts) that action had been taken to address these. However, in some cases advice and involvement of patients regarding safety alerts could have been timelier on occasion. We saw that DNACPR and ReSPECT forms had been completed in line with guidance and with the input of patients and when necessary, carers.

Leaders and managers told us that they had developed and adopted health and safety management processes to ensure the safety and wellbeing of patients, staff and visitors to the practice. Staff informed us that they had undertaken required mandatory training in respect of health and safety, such as annual fire safety training. Staff told us that they had no concerns related to health and safety in the practice. They confirmed that fire alarm tests and emergency evacuation drills had been undertaken and this was supported by records we examined.

We saw that the premises was in a good structural condition, and that equipment was maintained regularly, stored safely and was suitable for use. For example, fire extinguishers had recently been serviced, and clinical equipment had been calibrated to ensure that they operated correctly. In addition, facilities were suitable and safe for those with additional needs.

The provider had established management processes which gave assurance that health, safety and wellbeing requirements were met. For example, health and safety risk assessments had been undertaken in May 2024, and a fire safety risk assessment had been undertaken in November 2023. We saw evidence which showed that actions highlighted in the assessments had been completed when required. The provider had emergency medicines and equipment on site. From records we reviewed we saw that these were sufficient for the needs of the practice, and were checked and maintained as required. Practice zero tolerance procedures sought to ensure that staff were protected from patients who were abusive or aggressive.

We saw no indication of any concern in this area.

Leaders and managers told us that staffing levels were actively monitored, and that rotas were in place which ensured that there was the right mix of staff numbers and skills mix in place to deliver safe and effective care. When additional capacity was required, we were informed that recruitment would be undertaken, or agency staff and locums would be engaged. The provider told us that an additional 5 members of non-clinical staff had been recruited in October 2023 to meet demands. During our interviews with staff, they told us that they felt staffing levels were sufficient, and that in times of high demand that they all worked hard together and supported one another. When required overtime was available to staff. Staff told us that induction training was thorough, and that they had been able to gain additional skills, and had been supported to develop their career in the practice. Staff told us that they felt well supported by the provider, and found senior leaders and managers approachable, and willing to advise when additional support was required.

The provider had developed and adopted a recruitment policy which had been reviewed in October 2023. We saw that recruitment checks had been carried out in accordance with regulations, and that checks were also required for locum and agency staff. Other checks on staff included gaining assurance that staff vaccination was maintained in line with current guidance. Staff received the support they needed to deliver safe care. This included supervision, appraisal and continued professional development. For example, we saw records of clinical supervision of the Physicians Associate during sessional debriefings. This approach was supported by the development of staff appraisal, induction and clinical supervision policies. We saw that processes had been established to monitor and manage staff training and ongoing competency needs, and that mandatory training was up to date.

We saw no indication of any concern in this area.

Interviews and feedback from staff informed us that they had a good understanding of infection prevention and control. They were aware of how to raise concerns and who to contact when they identified issues. Staff who handled clinical specimens told us that they had received instruction how to do this safely.

We found the practice premises and equipment to be clean and hygienic, which protected people from the risk of infection. We saw within training records that staff had received infection prevention and control training annually. Cleaning schedules and records were in place and the cleaners cupboard was seen to be well organised and carry the appropriate equipment and cleaning materials.

There was an effective approach to assessing and managing the risk of infection. The provider had developed an Infection Prevention and Control (IPC) Policy which had been updated in November 2023. We saw that an IPC lead had been appointed by the provider and that IPC audits had been undertaken. IPC audits contained action plans for required improvements. We saw that issues identified at the most recent IPC audit in 2024 had been tackled and improvements made. The provider had contracts with external companies to support good IPC, this included a cleaning contract which was subject to monitoring, and a clinical waste contract. The provider had processes in place to assess the immunisation and vaccination status of staff.

We saw no indication of any concern in this area.

Leaders and managers at the practice told us that clinicians involved patients in assessments and reviews about the level and support they needed to manage their medicines safely, and that this was captured in medical notes. Prescribing clinicians met regularly, and best practice guidance was discussed at these meetings. The provider told us that they ensured that staff understood their roles in respect of medicines and that required training was monitored to ensure staff remain up to date with their skills and knowledge. At the time of the assessment, we were informed that the provider had no non-medical prescribers. In discussion with the practice pharmacist, we heard that he carried out duties which included medicines reconciliation, patient medicines reviews, and assessed incoming medicines and patient safety alerts. The provider did not have a formal process to ensure continued safe prescribing for patients who had not attended for required medicines monitoring, but had decided to develop a policy to support this work. Notwithstanding this at the time of inspection patients who did not attend we subject to repeated contacts to encourage attendance and when necessary prescribed lower amounts of medicines.

As part of our assessment a CQC GP specialist advisor (SpA) undertook a number of searches of patient records on the practice’s clinical records system. Overall, the searches showed that medicines had generally been effectively managed by the provider. Findings included: Methotrexate (used to treat rheumatoid arthritis, psoriasis, Crohn's disease and other autoimmune conditions) – all 15 patients had received the required monitoring in the last 6 months. Aldosterone Antagonist (used to treat heart failure) – Of 14 patients prescribed this only 1 patient was overdue monitoring. The provider had attempted to arrange an appointment with the patient, but had been unable to book one with the patient due to their unavailability. They had scheduled further checks to ensure that this was followed up, and had decided to formulate a policy on dealing with non-compliant patients. Over prescribing of Short-acting beta-agonist (SABA) inhalers (used to treat asthma symptoms quickly) – of 585 patients on the asthma register we found that 24 had potentially been over prescribed inhalers (12 or more) over the previous 12 months. We examined 5 of these in detail and saw that in 4 cases the provider had recognised the possible over prescribing and had arranged asthma reviews for these patients. In 1 case there were mitigating circumstances for prescribing. All 5 patients had received an asthma review within the previous 12 months. Medicine reviews – Over the previous 3 months 648 medicine reviews had been undertaken. From the 5 we examined in detail we found that there were no concerns with these. Safety alerts – The provider hade a process in place for receiving and actioning alerts. We examined an alert for SGLT-2 inhibitors (a diabetic medicine) which required patients to be made aware of specific symptoms for their own safety. We saw that all patients had been given advice, however in 3 cases this had only recently taken place and needed to have been made in a timelier manner.

The provider had in place measures for the management of medicines. This included processes for, repeat prescribing, patient reviews and monitoring, authorisations to administer medicines, and antibiotic stewardship. The provider undertook medicines improvement activity and had undertaken regular prescribing audits, and clinical audits which included a recent 2 cycle audit into prescribing Quinolones (an antibiotic). This audit showed that the provider had adhered to good prescribing practices. Medicines within the practice were effectively ordered, stocked and stored. For example, vaccine refrigerators had been regularly monitored to ensure temperature requirements were met, and emergency medicines held met the needs of the patient population and were also regularly checked. Accurate and up to date information about patient’s medicines was available, although it was noted that there was a historic summarising backlog which had been recognised and an action plan implemented to tackle this within 12 months. Measures were in place to manage patients in receipt of controlled drugs (medicines which are subject to high levels of regulation, management and oversight). The provider had processes in place to safely receive, handle, store and use prescription documentation.

Data showed that the provider had systems in place for the safe and appropriate use of medicines which included medicines optimisation. For example: Amoxiclav/Cephalosporins/Quinolones prescribing – the provider had prescribing levels of these antibiotics which were consistently below others, practice average 3.8%, local average 5.2%, and national average 7.8%. Prescribing in respect of Quinolones had been subject to internal clinical audit which supported this work. Other prescribing such as those related to hypnotics, psychotropics, and other antibiotic items showed that the provider was consistently close to local and national prescribing rates. We saw that performance in relation to medicines outcomes were closely monitored by the provider, and that this was discussed at monthly meetings.