Thorpewood Medical Group Also known as Woodside Surgery

Updated 14 December 2021

Thorpewood Medical Group is located in Norwich, Norfolk, within the Norfolk Clinical Commissioning Group (CCG) and provides services to approximately 13,200 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community. The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The provider has two sites in proximity known to patients as Woodside Surgery (main site) and Dussindale Surgery, Pound Lane, Thorpe St Andrew, Norwich, NR7 0SR (branch site). Patients can usually access services at either site, however due to COVID-19 the branch site was currently closed.

Thorpewood Medical Group has a team of clinicians including three male GP partners, two long term locum GPs (one male and one female), three female salaried GPs, two advanced nurse practitioners who can prescribe, one nurse who can prescribe, four practice nurses, a locum advanced emergency care practitioner who can prescribe, three healthcare assistants and a phlebotomist. The practice had a practice manager, an operational manager, reception, finance and information technology (IT) leads, a finance assistant and compliance assistant, who supported 16 administrative staff which included receptionists, secretaries and IT staff.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment at the main GP location.

The practice was open from 8am to 6:30 pm Monday to Friday and also provided pre-bookable appointments on Saturdays from 8am to 12 noon. Out of hours services are provided by Integrated Care 24 (IC24).

The practice population has a deprivation index level of seven, with one being the most deprived and ten being the least deprived. According to the latest available data, the ethnic make-up of the practice area is 96% White, 2% Asian, 1% Mixed and 1% Other.

The provider forms part of OneNorwich Primary Care Network, a group of 21 GP practices collaborating through four ‘neighbourhoods’ to deliver enhanced local care and treatment services. The practice has a physician associate, (works four days a week for the practice) a clinical pharmacist and a pharmacy technician (both work one day a week for the practice) who are employed by the PCN.

Updated 14 December 2021

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