Thornbury Medical Practice

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

Overall, we found that the practice was well-led. Following the last comprehensive inspection of the service in September 2023, the provider was rated inadequate for providing effective care and treatment. Issues identified included a lack ineffective policies containing not enough information or incorrect information, staff did not feel able to raise concerns, lack of strategy or plan in accordance with the clinical governance policy and no evidence of systems and processes for learning, continuous improvement and innovation. We carried out a follow up inspection in January 2024 and found that the provider had taken appropriate steps to address these areas.

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.

Staff feedback regarding the culture of the practice was positive. Some feedback acknowledged an improvement in culture following the previous inspection, others told us how they considered the practice to be a great place to work.

The practice had a clear plan which outlined strategic direction over next 3 years. This contained set ambitions and outlined how progress towards these will be measured. Improvements such as childhood immunisations were included as an area of performance monitoring. The plan also focuses on supporting colleagues as in order to improve lives they need to make sure the practice team is healthy and fulfilled in their roles.

Staff told us that managers and leaders were friendly, approachable and very supportive. Managers told us how they had introduced an open-door policy to ensure staff had appropriate support when required. We were informed that the practice was in the process of trying to implement a daily huddle but had found this difficult due to differing working patterns of staff.

The practice had introduced surveys to obtain feedback from staff. There was dedicated time for practice learning in which concerns and suggestions were discussed and regular practice meetings which all staff were invited to attend.

Staff we spoke with and received feedback from told us they knew how to raise concerns and felt comfortable to do so.

There was a comprehensive freedom to speak up policy with details of the process to follow and external freedom to speak up guardians. Concerns could be raised openly and confidentially or anonymously to support any staff members raising concerns. There was a duty of candour policy in place which included links to a standard letter which could be used to inform patients of any incidents. The policy clearly outlined degrees of harm and reference to appropriate Care Quality Commission Guidance.

Staff we spoke with, and received feedback from, told us they felt supported by the practice leaders and their colleagues. We heard examples of how staff feedback had been used to improve the process for dealing with sick note requests.

There were systems and processes in place to support the safety and well-being of staff. This included clear policies such as lone working and zero tolerance. The provider had also carried out staff surveys to obtain feedback, introduced an employee of the month award which was rewarded with a voucher, and had social events planned. For example, they had arranged to take all staff for a meal in July and had a team building exercise scheduled to take place in August. In addition, all staff had access to yoga sessions at the practice learning events.

Staff told us there were clear responsibilities, roles and systems of accountability to support good governance and management. They told us they were able to access policies and procedures to support them within their role and attended regular meetings where discussions about the practice, such as complaints, significant events and improvements, were discussed. Staff told us they were clear about their roles and responsibilities and knew who to contact should they need any advice or have any concerns. We heard of succession planning to support the future of the practice. For example, practice nurses having the opportunity to develop into leadership roles, and a member of the management team being supported to be involved in financial and human resources aspects of the practice.

There was an organisational structure in place which clearly identified line management responsibilities. The practice had dedicated leads for areas such as safeguarding, complaints, data protection. Information was stored on a shared drive, which all staff had access to. We saw that policies and procedures were up to date and relevant. There were clearly documented agendas and minutes of both practice and clinical meetings, these covered areas including staff training, patient safety alerts, complaints, compliments and significant events. We saw there was an up to date business continuity plan which covered areas such as arrangements in place with other practices within the primary care network for the use of rooms in the event of short or long term loss of access to premises. The plan contained details of key staff members, other stakeholders and service providers. Staff used data to monitor and improve performance. The provider had produced action plans to address areas of lower performance such as childhood immunisations and cervical screening. We found workflows for communication and pathology results were up to date at the time of our assessment.

Only one patient had reviewed the practice via the NHS website which raised concerned about access. The practice had not responded to this review. Feedback from representatives from the patient participation group was positive regarding their interactions with the practice. They told us they felt listened to by the practice and that their views were acted upon.

Staff gave examples of engagement and joint working with other services, both for the benefit of patients and also to support staff in undertaking their roles.

We saw evidence of proactive partnership working with statutory and voluntary sector organisations.

The practice worked with stakeholders to build a shared view of challenges and of the needs of the population. The practice worked with a range of external partners, for example, other health and social care professionals, mental health services and voluntary sector organisations to support patients with a range of needs.

There was a learning culture in the practice which staff and leaders actively participated in. Staff spoke positively about the culture of the practice and their role within it. Staff told us they had access to relevant training to support them in their role.

There were systems and processes for learning, continuous improvement and innovation. In response to low uptake of cervical screening and childhood immunisations, the practice had taken steps to engage with local community groups to educate and promote the health benefits. The practice used clinical audit to monitor and drive improvement. The practice had carried out two-cycle audits to review quinolones prescribing and monitoring of patients with coeliac disease. We reviewed the audits and found that improvements were evidenced in both cases. The practice had responded positively to address the concerns raised in our previous comprehensive inspection in September 2023. This included proactively requesting support from other organisations including NHS West Yorkshire Integrated Care Board, Local Medical Committee and the Royal College of General Practitioners to make improvements and improve management oversight. The practice had focused on staff wellbeing and introduced incentives such as employee of the month programme, with the winner receiving a certificate and a voucher as acknowledgement.