Thorpe-le-Soken Surgery

Updated 18 October 2022

Thorpe Surgery is located in the village of Thorpe-le-Soken in Essex at:

The Surgery

High Street,

Thorpe-le-Soken,

Essex,

CO16 0EA

The practice has a branch surgery at:

Kirby Cross Branch

Frinton Road

Kirby Cross

Essex

CO13 0HJ

The practice provides a dispensing service which we inspected as part of this inspection activity. The practice dispenses to approximately 900 patients.

The practice is situated within the NHS Suffolk and North East Essex Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of approximately 8,100. This is part of a contract held with NHS England.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures. These are delivered from both sites.

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is part of a wider network of six GP practices.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 0.6% Asian, 98.2% White, 0.6% Black, and 0.6% Other.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of five GPs who provide cover at both practices. The practice has a clinical team of three emergency care practitioners, three advanced nurse practitioners two practice nurses, and two healthcare assistants who provide minor injury and clinics for long-term condition management at both the main and the branch locations. The GPs are supported at the practice by three dispensers, a team of eight reception/administration staff, and two secretaries. The practice manager and assistant practice manager are based at the main location to provide managerial oversight.

The practice is open between 8am to 6.30pm Monday to Friday and 8am to 12.30 pm on Saturday. At the branch site they are open 8am to 7.45 Monday and 8am to 4pm Tuesday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided by a practice locally in the PCN group, where late evening and weekend appointments are available. Out of hours services are provided by the 111service.

Updated 18 October 2022

We carried out an announced inspection at Thorpe-le-Soken Surgery on Friday 05 August 2022. Overall, the practice is rated as Good.

Safe – Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

Following our previous inspection on 01 December 2015, the practice was rated Good overall and for safe, effective, caring, and responsive key questions and Outstanding for Well-led:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Thorpe Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach. This was a comprehensive inspection that included:

• Inspection of the key questions:
• Safe
• Effective
• Caring
• Responsive
• Well-led

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Staff questionnaires.
• A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• Patients with safeguarding identified had been discussed in safeguarding meetings and alerts attached to patient’s records.
• Health and safety, risk management systems including fire, the dispensary, and medicines management processes, were well managed.
• Although we found no concerns with infection control an audit had not been undertaken for over two years and this included hand washing audits.
• We found nine patients taking one of the high-risk medicines had not received one part of the expected monitoring. Six patients taking medicine for hypothyroidism had not received a blood test check for 18 months, and three of the five diabetic patients we reviewed had not received a face to face review or diabetic retinopathy screening in the last 18 months. Immediately actions were taken on our findings by the practice to ensure patients received this monitoring. At the on-site visit we were shown how their new protocol was working however, this process needed to be monitored and embedded.
• We found some patients had a potential missed diagnosis of diabetes and chronic kidney disease. The practice took immediate action and changed their monitoring process to ensure this did not happen in the future.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice respected patients’ privacy and dignity, and patient confidentiality was maintained throughout the practice
• The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic, they had increased infection control cleaning processes and replaced flooring and seating.
• The practice was led and managed to promote the delivery of high-quality, person-centred care.

We found a breach of the regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Continue to encourage patients to attend for cervical cancer screening.
• Continue to encourage patients aged five to receive two doses of measles, mumps and rubella vaccination.
• Continue to encourage patients to participate in a patient participation group (PPG).
• Continue to improve access to the practice via the telephone.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services