The Care Quality Commission
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Thornbury Medical Practice

Overall: Good read more about inspection ratings

Rushton Avenue, Bradford, West Yorkshire, BD3 7HZ (01274) 662441

Provided and run by:
Thornbury Medical Practice

All Inspections

During an assessment under our new approach

Date of assessment 12 June to 21 June 2024

Thornbury Medical Practice is located on Rushton Avenue, Bradford, West Yorkshire BD3 7HZ.

The provider is registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures.

The practice is situated within the NHS West Yorkshire Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 7,150.

The practice works with 9 other local GP practices in the PCN 5 primary care network.

The practice is open between 8am to 6pm Monday to Friday, and has extended hours opening between 7am and 8am on Thursdays.

The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally through a federation and PCN working where late evening and weekend appointments are available. Out of hours services are provided by Local Care Direct Limited.

The practice was previously inspected in September 2023 and rated inadequate overall. We placed the practice into special measures. A follow up inspection was undertaken in January 2024, to check progress against the breaches of regulation identified, however this inspection was unrated.

We carried out this assessment to review the practices current performance and found the practice to have taken appropriate steps to address the issues previously identified. Therefore, we are removing this practice from special measures.

19 January 2024

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 6 September 2023. The overall rating for the practice was inadequate, and the service was placed into special measures. Warning notices were subsequently served on the provider for breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulations 16 Receiving and acting on complaints, Regulation 17 Good governance, and Regulation 19 Fit and proper persons employed. The full report of this comprehensive inspection can be found by selecting the “all reports” link for Thornbury Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was an announced focused inspection carried out on 19 January 2024 to check that the provider had responded to the warning notices dated 8 September 2023, and met the legal requirements in relation to the breaches of Regulation 16, Regulation 17, and Regulation 19. The provider was required to be compliant with the matters documented in the warning notices by 22 December 2023.

This report covers our findings in relation to those requirements. The inspection has not resulted in any new rating and the practice remains rated as inadequate and in special measures.

How we carried out the inspection/review

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 remotely and during a short on-site visit.

• Reviewing records to clarify actions taken by the provider.

• Requesting and reviewing information from the provider.

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 the provider.

We found that:

  • The provider had made the required improvements in the areas identified in the warning notices.
  • The provider had systems and processes in place to ensure that staff work histories, including gaps in employment, had been recorded. Systems and processes were also in place to ensure that professional qualifications were assessed and copies of these held, and that professional registration checks for clinicians had been carried out.
  • The provider had established and implemented a system for identifying, receiving, recording, and handling complaints. Actions taken by the provider included updating the complaints policy and complaints leaflet. We saw that complaints had been responded to in a timely manner, and that learning from complaints had been shared with staff and used for service improvement.
  • We saw that essential policies and procedures had been reviewed and updated, and carried accurate information. This included the whistleblowing policy, training policy, and the clinical governance policy.
  • The system to authorise practitioners to administer certain medicines had been reviewed, and we saw documentation which showed that such staff had been properly authorised.
  • The provider had appointed a Freedom to Speak Up Guardian to provide support to staff who wanted to raise concerns. Staff we spoke with told us that they felt able to raise concerns with the leaders and managers at the practice, and were aware of the newly appointed Freedom to Speak Up Guardian.
  • The provider had established and implemented a new system for managing significant events and incidents. We saw that when identified, these had been investigated, and that any learning had been shared with staff at team meetings, and used to improve services.
  • The provider had implemented new systems and processes to monitor and manage staff training. We saw that staff training was up to date.
  • The provider had reviewed and updated information given to locum GPs and agency staff to allow them to carry out their duties. This included information about safeguarding and referrals.
  • We saw that meetings were minuted, and that these minutes were detailed and contained sufficient information to guide those staff who had not been able to attend the meetings.

Whilst we found no breaches of regulations, the provider should:

  • Upload the updated complaints policy and complaints leaflet to their practice website.

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 Health Care

6 September 2023

During a routine inspection

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 6 September 2023. Overall, the practice is rated as inadequate overall, with the following key question ratings:

Safe - inadequate

Effective - inadequate

Caring – requires improvement

Responsive - inadequate

Well-led - inadequate

Our previous full comprehensive inspection was on 17 May 2018. The practice was rated good overall and good for all key questions except caring, which was rated requires improvement. We carried out a focused inspection on 4 April 2019, which reviewed the caring key question. Following that inspection the practice was rated good for caring and good overall.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns which were reported to us.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A 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 rated the practice inadequate for providing safe services:

  • There was no accurate list of patients with a safeguarding need, and evidence of long-term locum clinicians completing training was not always kept.
  • The practice did not carry out all the relevant recruitment checks.
  • The infection control audit did not identify issues we found during the inspection, and fire safety and health and safety audits were not managed effectively.
  • Relevant information was not provided to locum clinicians.
  • Patient Group Directions (PGDs) were not managed so not all clinicians were appropriately authorised to administer medicines.
  • Significant events were not all recorded or investigated. They were rarely discussed within the team and the system for learning when things went wrong was not effective.

We rated the practice requires inadequate for providing effective services:

  • The most recent verified data for childhood immunisations and cervical screening were below the national targets.
  • There was no practice quality improvement programme. Audits were carried out by pharmacists and those provided did not demonstrate quality improvement.
  • Staff training had not been monitored and was not carried out in accordance with practice policies.
  • There was limited evidence of appraisal and supervision for staff.

We rated the practice requires improvement for providing caring services:

  • The National GP Patient Survey showed that patient satisfaction had decreased.
  • There was limited information available to help patients cope emotionally with their care.

We rated the practice inadequate for providing responsive services:

  • Complaints were not used to improve the quality of care.
  • Some of the GP Patient Survey results were below local and national averages.
  • The practice did not adequately seek and act on feedback from patients.

We rated the practice inadequate for providing well-led services:

  • GP partners did not have any oversight of non-clinical aspects of the practice.
  • The practice did not have a strategy or plan in accordance with its clinical governance policy.
  • We saw examples of policies containing incorrect information, not enough information or not being followed. They had not been updated on the date recorded on the policies.
  • The culture of the practice did not enable staff to raise concerns.
  • Overall governance procedures were not effective.
  • Data breaches had not been reported and statutory notifications not appropriately completed.
  • There was no evidence of systems and processes for learning, continuous improvement and innovation.

We found 5 breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation, and ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

In addition, the provider should:

  • Take action to improve their uptake of childhood immunisations and cervical screening.

I am placing this service in special measures. Services placed in special measures will be inspected again within 6 months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within 6 months if they do not improve.

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 Health Care

19/03/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 17 May 2018. The overall rating for the practice at that time was good. However, the practice was rated as requires improvement for providing caring services. The full comprehensive report on the May 2018 inspection can be found by selecting the ‘all reports’ link for Thornbury Medical Practice on our website at www.cqc.org.uk .

This inspection was an announced focused follow up inspection carried out on 19 March 2019 to review the practice in relation to the key question of caring and the services offered to patients. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

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 for providing caring services.

We found that:

  • The practice had identified an increased the number of patients who were carers and were offering health and social opportunities and support for these patients.
  • The practice had reviewed and responded to the GP patient survey 2018. Changes were made as a result of feedback from patients.
  • The provider had considered the needs of vulnerable patients and offered priority appointments and telephone support to suit individuals.

At the inspection on 17 May 2018 we highlighted a number of areas where we said the practice should improve. At this inspection we saw that:

  • The practice had increased the prevalence of patients with mental health needs to 1% which was above CCG average. The practice had identified a GP mental health lead who, with support from a member of the administration team, regularly reviewed the needs of patients on the mental health register. The practice survey showed that 82% of patients felt their mental health needs were met during their last consultation. Three separate invitations were sent to this patient group to remind them of their reviews. If this method failed, the GP would ring the patient. For patients who declined to attend for reviews support would be offered over the telephone. The practice worked with local mental health teams to ensure the needs of this vulnerable group were met.
  • A new recall system was in place to encourage and monitor cervical screening at the practice. The team were targeting young people before their 25th birthday to proactively offer screening. Reports were run and reviewed by the nursing team every 30 days and additional letters printed on pink paper. Telephone calls were made to those who had failed to attend. The practice nurse was allocated six hours per month to review, call and support patients to attend for screening. Outcomes were reviewed with the GP screening lead, at nurse and clinical meetings and by way of a bi-annual audit. Outcomes for breast and bowel cancer screening were above national averages.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information

17/05/2018

During a routine inspection

This practice is rated as good overall but is rated as requires improvement for providing caring services. (Previous inspection 28 September 2017- requires improvement.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Requires improvement

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 28 September 2017. The practice was rated as requires improvement in the key questions of responsive and well led. The overall rating for the practice was requires improvement. The full comprehensive report for the September 2017 inspection can be found by selecting the ‘all reports’ link for Thornbury Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 17 May 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 28 September 2017. This report covers our findings in relation to those requirements.

Overall the practice is now rated as Good overall.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. We found that this was not always clearly documented at every stage of the process, but staff told us they were discussed at monthly meetings and they had good knowledge of these.
  • The practice had established systems and processes which had improved the safety and quality of the service provided.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • The results of the July 2017 GP patient survey showed patients did not always find the appointment system easy to use and the satisfaction with clinical consultations was below average. However, patient feedback on the day of inspection reflected that access to the service had improved and the availability of appointments had increased.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • Regular meetings were held at the practice and the minutes were available to all staff.
  • The practice offered a walk-in clinic for appointments twice per month. Five clinicians were available to see patients during the morning session. In addition, patients could monitor their basic health with support from the advanced clinical practitioner at each fortnightly Wednesday drop in clinic.
  • A weekly welfare contact was made by a designated member of staff with the patients at the practice noted to be vulnerable. Patients were asked if they had enough medication, how they were and if they required any further support.

The areas where the provider should make improvements are:

  • The provider should continue to review and take steps to improve the uptake of cancer screening at the practice, including bowel, breast and cervical screening.
  • The provider should continue to review and respond appropriately to the results of patient satisfaction surveys, in particular supporting patients to feel involved in decisions about their care and treatment and ensure that they can meet the needs of their patient population in the future.
  • Continue to improve the identification of carers to enable this group of patients to access the care and support they require.
  • The provider should continue to review and improve, where possible, access to health care for patients with mental health needs.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

28 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 28 September 2017. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report complaints and significant events. However, the outcomes of these reviews and any lessons learned were not regularly discussed at staff meetings or shared with staff.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. The practice had identified that not all the senior staff at the practice had received safeguarding training to the required level.
  • Data showed patient outcomes were comparable to local and national averages.
  • The latest National GP Patient Survey results for the practice showed lower than average numbers of patients said they were treated with care and concern by their GP. The survey data also showed that patients found making and accessing appointments difficult. However, the majority of patient comment cards and patients with whom we spoke on the day did not confirm this opinion, and said that access to appointments had recently improved.
  • The practice had a number of policies and procedures to govern activity, but some were not dated or were overdue a review.
  • Risks to staff and patients were assessed and well managed, with the exception of those relating to the administration of medicines by Patient Group Directions (PGDs). We saw PGDs had been adopted by the practice to allow nurses to administer medicines in line with legislation but we found that these had not been signed by the authorising body. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.)
  • The practice did not maintain oversight of the immunisation status of the staff team and did not follow their own policy with regards to the Hepatitis B immunity status of staff.
  • There was a clear leadership structure and staff felt told us that they felt very supported by management. The practice had a patient participation group and health champions which met regularly.
  • The pharmacist had undertaken an audit of patients who required a medication review. A high number of these were found to be overdue and a system had been implemented to address this issue.

The areas where the provider must make improvements are:

  • 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 review the results of patient satisfaction surveys and ensure that it can meet the needs of their patient population in the future and improve outcomes.
  • Continue to review access to the service and assure themselves that they are able to provide an appropriate number of appointments to meet patients’ needs.
  • Continue to review the medication needs of all patients and be able to assure themselves that all patients’ medications are reviewed as required.
  • Implement a schedule for the cleaning of clinical equipment to assure themsleves that this meets best practice for infection prevention and control.
  • Continue to improve the identification of carers to enable this group of patients to access the care and support they require.
  • Continue to take steps to improve their cancer screening uptake rates within their population including breast and bowel screening.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Wednesday 8 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thornbury Medical Practice on 10 November 2015. Overall the practice was rated as good. However of the practice was rated as requires improvement in the key question of Responsive. After the inspection the practice wrote to us to say what they would do to meet the requirements in relation to the responsiveness of the practice.

We undertook a focussed follow up inspection at Thornbury Medical Practice on 8 February 2017 to check that the practice had made the improvements required. This report only covers our findings in relation to those requirements. The practice is now rated as good for providing responsive services.

You can read the full comprehensive report which followed the inspection in November 2015 by selecting the 'all reports' link for Thornbury Medical Practice on our website at www.cqc.org.uk.

Our key findings across all the areas we inspected were as follows:

  • There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. For example via the PPG newsletter and via protective learning time for staff.
  • The practice developed effective ways of deploying temporary staff e.g. Locums. The practice now only used two long term locums.
  • The practice looked at ways of making sure patients had access to prompt medical care. The practice had an on call system everyday weekday from 8am to 6pm.
  • The practice explored avenues of staffing and skill mix to ensure the practice was adequately staffed in the medium to long term. The practice now employed a full time health care assistant.

The provider should:

  • The practice should continue to monitor and take steps to improve patient’s satisfaction with access to the practice by telephone.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Tuesday 10 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thornbury Medical Centre on 10 November 2015. Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • On the whole patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. There were some accesses problems that the practice needs to address.
  • The practice had facilities and was equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw areas of outstanding practice:

  • A flu vaccination analysis was implemented recently in conjunction with the local pharmacist which resulted in saving the practice 850 appointments. The practice manager told us that Flu clinics for inviting patients were sent out. The practice set up a structured campaign targeting certain groups of patients and also giving opportunistic vaccinations with the largest increase being in pregnant women.

The areas where the provider should make improvement are:

  • The practice should explore effective ways of deploying temporary staff e.g. Locums.

  • Effectively investigate performance data and patient feedback which might indicate potential risks to care.

  • Look at ways of making sure patients have access to prompt medical care.

  • Explore all avenues of staffing and skill mix to ensure the practice is adequately staffed in the medium to long term.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 September 2013

During a routine inspection

Patients told us they were treated with care and respect and we saw positive interactions between patients and staff. One person said, 'They're alright here, I've been coming for years here'. All the patients we spoke with told us there could be problems getting an appointment although once they had got through to the surgery the service offered was good.

The staff we spoke with were aware of their responsibilities to report safeguarding matters to the relevant safeguarding authorities and to the Care Quality Commission (CQC).

An infection control policy was in place which was reviewed regularly.

The Practice Manager was aware of the recent changes from Criminal Record Bureau (CRB) checks to Disclosure and Barring Service (DBS).

People were made aware of the complaints system and details were available on the scrolling computerised practice screen above reception. This was provided in a format that people could understand and gave details of who to speak with.