• Doctor
  • GP practice

Thistlemoor Road Surgery

Overall: Outstanding read more about inspection ratings

6-8 Thistlemoor Road, Peterborough, Cambridgeshire, PE1 3HP (01733) 551988

Provided and run by:
Thistlemoor Road Surgery

Latest inspection summary

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Background to this inspection

Updated 11 May 2022

Thistlemoor Medical Centre is located in the region of Cambridge and Peterborough at:

The Surgery

Thistlemoor Rd

Peterborough

PE1 3HP

01733 551988

https://www.thistlemoor.co.uk

The Surgery is sited in a residential area close to the city centre of Peterborough. It serves approximately 29,500 registered patients and has a general medical services contract with Cambridgeshire and Peterborough Clinical Commissioning Group (CCG).

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

Compared with other practices in the area, it has a higher proportion of patients under the age of 18 and a lower proportion of patients over the age of 65. It has a more deprived population than the CCG and the England averages. Specifically, the area has greater income deprivation affecting children and older people than the CCG and England averages.

The practice serves a diverse population with the majority of patients coming from eastern European countries such as Poland, Lithuania, Russia and the Czech Republic. These patients total more than 80% of the practice population.

The practice consists of 15 GPs (six male, nine female), 10 nurses, one advance care practitioner and 20 health care assistants. There are five clinical pharmacists. They are supported by a full-time practice manager and a number of reception and administrative staff. They provide placements to medical students, as well as doctors preparing to be GPs and physician associates.

The practice is open between 8.30am and 6.30pm Monday to Friday. Extended hours surgeries are offered between 7am-8am on weekdays, and from 8am to 10am on Saturdays. The practice offers extended hours appointments on evenings and weekends through a Federation of local practices.

Many of the GPs and other staff help support this work alongside providing additional appointments at the surge hub which is located at Parnwell Medical Centre.

Patients can ring, email or use engage consult, an online platform to contact the practice. Patients will be assessed and will be offered a face to face appointment when needed. The practice continues with face to face appointments for cervical smear tests and procedures.

Outside of practice opening hours patients can access pre-bookable evening and weekend appointments through a network of local practices. In addition to this, a service is provided by Herts Urgent Care, by patients dialling the NHS 111 service.

Overall inspection

Outstanding

Updated 11 May 2022

We carried out an announced inspection at Thistlemoor Medical Practice on 10 March 2022. Overall the practice is rated outstanding.

The ratings for each key question were:

Safe - Good

Effective - Good

Caring - Good

Responsive - Outstanding

Well-led - Outstanding

This was a follow up inspection on 11 February 2021 when the practice was rated Good overall. This was a down grading from Outstanding previously, because the practice was rated Requires Improvement for the key question Safe. At this inspection we found that action had been taken in all the areas where concerns had previously been identified. In addition, at the last inspection they remained outstanding in the key question Responsive.

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

Why we carried out this inspection

This was a comprehensive inspection to check that the practice had met the breaches identified at the previous inspection. The inspection was undertaken at the same time as we inspected a range of urgent and emergency care services in Cambridge and Peterborough, to help us understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

The focus of the inspection included :

  • Key questions inspected including Safe, Effective, Caring, Responsive and Well led.
  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection in the key question Safe.
  • Additional questions in relation to urgent and emergency care.
  • Ratings carried forward from 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

  • Conducting some staff interviews using video conferencing
  • 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
  • Requesting evidence from the provider
  • A shorter 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 Outstanding overall

We found that:

  • GPs at Thistlemoor Road Surgery in Peterborough had developed a radical model for the role of the healthcare assistant in general practice. In May 2007 that role was evaluated by Sheffield University which found it to be safe, effective and well-liked by patients. The model had been benchmarked and evaluated by other Clinical Commissioning Groups and was found that if adopted, would create efficiencies of around £72m.
  • Care and treatment was targeted specifically to the needs of the patient population rather than by headcount. This was found to be particularly effective at providing good outcomes for a transient patient population, 80% of whom did not have English as their first language.
  • The practice had received several awards and had been recognised nationally for their input into the National Health Service. The lead GP had received an MBE in 2021 for their contribution to the NHS and general practice, including the development and growth of Thistlemoor Road Surgery from 700 to 29,500 patients over its 30 years.
  • The focus of the practice was now to see how they could continue to make a difference throughout the whole of the Peterborough Community.
  • Care was provided in a way that kept patients safe and protected them from avoidable harm. They received effective care and treatment that met their needs. Staff dealt with patients kindly and respected and involved them in decisions about their care in their own languages, of which there were many.

We rated the provider as Outstanding for providing responsive services. We found that:

  • Patients’ individual needs and preferences were central to the delivery of services which were tailored according to the diverse language and cultural needs of the patient population.
  • The practice proactively assessed and reviewed the needs of its patient population and adjusted its workforce and appointment system accordingly.
  • There was evidence of innovative models which had been developed to ensure all patients, including those most vulnerable received good quality care in a timely manner. Those models had been promoted to and adopted by other practices both regionally and nationally.
  • Evidence of patient satisfaction was demonstrated through direct feedback on the day of the inspection, reviews kept by the practice which were shown to the inspection team, and the practice’s own patient feedback.
  • The staff had been proactive in giving education talks about COVID-19, prevention measures and encouraging uptake of the vaccination.

We rated the provider Outstanding for providing well led services. We found that:

  • The practice’s mission statement was to provide excellent, holistic and sustainable healthcare, as an employer of choice and continue to be the Practice of the future.
  • There was an embedded system of leadership, development and succession, and staff were employed to fit the model. They were trained ensuring the basic fundamentals of care specifically met the needs of their diverse population.
  • Leaders had an inspiring shared purpose and strove to deliver and motivate staff to succeed. There were high levels of staff satisfaction.

The practice should:

  • Continue to use the searches in the clinical system to ensure good medicines optimisation and safe prescribing.

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