This practice is rated as Good overall. (Previous rating December 2017–Requires improvement)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Thorpe Hesley Practice on 23 October 2018 to follow up on breaches of regulations identified at our inspection on 29 November and 7 December 2017.

At this inspection we found:

• Improvements had been made to systems for the management of health and safety and action plans had been implemented and monitored.
• When incidents happened, the practice learned from them and improved their processes.
• Recruitment procedures had been improved and systems to monitor staff training and registration with appropriate professional bodies had been implemented.
• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a focus on continuous learning and improvement in the organisation.

The areas where the provider should make improvements are:

• Develop opportunities for peer support and to share learning with the nursing team.
• Improve records relating to safety alerts to include actions taken.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

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

Letter from the Chief Inspector of General Practice

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires Improvement

We carried out an announced comprehensive inspection at Thorpe Hesley Practice on 29 November and 7 December 2017 as part of our inspection programme.

At this inspection we found:

• There were processes for managing risks, issues and performance. We found management of health and safety and recruitment procedures required improvement. The practice had recognised most of the areas for improvement prior to the inspection and had employed external companies and implemented recognised improvement tool kits to assist them. However, they had failed to monitor progress to implement action plans and some actions had not been completed to address shortfalls.

• 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.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

• Assess monitor and mitigate risks relating to health safety and welfare of patients and others who may be at risk.

• Ensure recruitment procedures are established and operated effectively.

• Maintain records relating to the management of the practice.

• Ensure persons employed are registered with the relevant professional body where such registration is required in relation to the work they perform or the title they take.

• Ensure staff have the qualifications, skills, competence and experience which are necessary for the duties performed by them.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice