The Care Quality Commission
  • Doctor
  • GP practice

Thorpewood Medical Group Also known as Woodside Surgery

Overall: Requires improvement read more about inspection ratings

140 Woodside Road, Thorpe St Andrew, Norwich, Norfolk, NR7 9QL (01603) 701477

Provided and run by:
Thorpewood Medical Group

All Inspections

24 November 2021

During a routine inspection

We carried out an announced inspection of Thorpewood Medical Group on 24 November 2021. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led – Requires improvement

Following our previous inspection on 14 April 2020, the practice was rated requires improvement overall and for providing safe, effective, responsive and well led services. They were rated good for providing caring services. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Thorpewood Medical Group on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out an announced comprehensive follow up inspection at the practice to review in detail the actions taken by the provider to improve the quality of care. The focus of this inspection included:

  • The key questions of safe, effective, caring, responsive and well led.
  • The follow up on breaches of regulations and areas where the provider ‘should’ improve identified in our previous inspection.

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:

  • Requesting evidence from the provider and reviewing this.
  • 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.
  • Conducting staff interviews using video conferencing and by telephone.
  • Gaining feedback from staff by using staff questionnaires.
  • Requesting and reviewing feedback from the Patient Participation Group.
  • 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 requires improvement overall. The practice was rated good for effective and caring and requires improvement for safe, responsive and well-led services.

We found that:

  • Significant improvements had been made to some of the areas identified at our last inspection. However, our inspection identified other areas for improvement as the practice did not always ensure the safe management of medicines.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • At this inspection we found national patient survey data remained below local and national averages. Whilst the practice had put actions in place to improve access, these changes required embedding and evaluation to determine their effectiveness.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care. We identified some of the practice systems and processes in place to ensure good governance were not wholly effective. Where improvements were made immediately following our inspection, they needed to be monitored and embedded to ensure they were effective and sustained.

We found one breach of regulation. The provider must:

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

There were other areas the provider could improve and should:

  • Improve patient experience in relation to the provision of responsive services.
  • Continue to monitor the provision of the national cervical cancer screening programme to improve uptake.
  • Continue to reduce the backlog of summarising.
  • Review policy on Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) to ensure this is in line with evidence-based guidance.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

06 February to 07 February 2020

During a routine inspection

We carried out an announced inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Are services at this location safe?
  • Are services at this location effective?
  • Are services at this location caring?
  • Are services at this location responsive?
  • Are services at this location well-led?

At our last inspection in July 2015 we rated the practice as Outstanding overall in line with our ratings aggregation principles. The practice was rated as outstanding for providing effective, responsive services and well-led services. We rated the provider as good for providing safe and caring services.

At this inspection we rated the provider as requires improvement overall.

We rated the provider as requires improvement for providing safe services because:

  • The provider had not ensured the premises were safe for their intended purpose and had not ensured the proper and safe management of medicines.

We rated the provider as requires Improvement for providing effective services because:

  • The practice exception reporting rates were significantly higher than local and national averages for the population groups people with long term conditions and people experiencing poor mental health (including people with dementia).
  • Annual reviews were not available for housebound patients with long term conditions such as asthma and COPD.

We rated the provider as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the provider as Requires Improvement for providing responsive services because:

  • Data from the national GP patient survey was significantly below the local and national average and showed that patients were not always able to access care and treatment in a timely way.
  • These issues affected all population groups and as such we have rated all population groups as requires improvement.

We rated the provider as requires Improvement for providing Well-led services because:

  • The provider did not have effective governance arrangements in place to identify and mitigate risks to staff and patients.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to monitor GP patient survey data to improve patient experiences related to the provision of caring services.
  • Review the provision of the national cervical cancer screening programme to improve uptake beyond the 80% national target.
  • Review and improve the identification of carers to ensure appropriate care and support are offered to these patients.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14th July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We conducted a comprehensive announced inspection on 14th July 2015.

The overall rating for this practice is outstanding.

We found that the practice was outstanding in relation to being effective, well led and responsive to patients’ needs. They provided a safe, effective, caring, responsive and well led service.

They were outstanding for being well led, effective and responsive in providing services for people living in vulnerable circumstances. They were outstanding for well led and responsive to families, children and young people. The practice was outstanding in their effectiveness and responsiveness in providing services to older people and they were outstanding in their effectiveness for people with long term conditions. They were good for working age people (including those recently retired and students), and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed, addressed and shared with staff during meetings.

  • Risks to patients and staff were assessed and managed. There were risk management plans which included areas such as premises, medicines handling and administration, infection control and safeguarding vulnerable adults and children.

  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.

  • Staff had received training appropriate to their roles. Staff were supervised and supported and any further training needs had been identified and planned for.

  • Patients were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. They told us that access to appointments with GPs and nurses was good and that they were happy with the treatments they had received.

  • Information about services and how to complain was readily available and easy to understand. Complaints were handled and responded to in line with relevant guidelines.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.

We saw a number of areas of outstanding practice.

  • The practice had written two policies which the local Clinical Commissioning Group (CCG) had adopted and distributed to the other Norfolk practices. These were a transgender policy, which was a response to an identified need within the practice and local CCG and an adoption policy created from working with National Adoption Advisors. They had identified the need for the policy within their CCG and were currently using both.

  • The GPs worked closely with drug dependence teams to support vulnerable patients such as those with a drug and alcohol addiction or those with poor mental health. They received referrals from and made referrals to the Norfolk Recovery Partnership which was a Norfolk wide initiative. The practice independently built a relationship with the East Coast Recovery service to forge a stronger and wider impact to assist vulnerable patients. They worked closely with the Norwich Admiral Nurse for dementia care. Admiral Nurses are specialist dementia nurses who give practical and emotional support to family carers, as well as the person with dementia.

  • The practice organised external disability awareness and visual awareness training and changes were made to the way the practice accommodated these patients. For example, help was offered to patients with check-in and registration and a lower area of the reception desk was installed after consultation with patients about the design so that staff could greet patients with mobility problems at their level.

  • The practice had a specialist prescribing nurse who was dedicated to palliative care, at risk patients, elderly dependant patients, housebound patients, out of hours’ referrals and clinics at the care homes that were supported by the practice. The work of the specialist nurse had cut the risk of a repeat admission by over half to the statistical expectation.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice