We carried out an announced inspection at Thornbury Road Centre for Health on 20 May 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 19 September 2019, the practice was rated Requires Improvement overall and requires improvement overall for all population groups. We rated the practice as requires improvement for providing safe and responsive services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Thornbury Road Centre for Health on our website at www.cqc.org.uk.
Why we carried out this inspection
This was a comprehensive inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance.
At this inspection we covered all key questions:
- Are services safe?
- Are services effective?
- Are services caring?
- Are services responsive?
- Are services 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 included:
- Conducting staff interviews on-site.
- Completing clinical searches on-site 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
- A full-day 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 and Good for all population groups.
We found that:
- The practice had demonstrated improvements in governance arrangements compared to the previous inspection.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- 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.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Review staff feedback regarding non-clinical staffing levels.
- Review the patient participation group (PPG) feedback regarding further improving the engagement and access to the service.
- Continue to encourage and monitor childhood immunisation uptake rates.
- Take necessary action to reissue the electrical installation condition report.
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