The Care Quality Commission
  • 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

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Thistlemoor Road Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Thistlemoor Road Surgery, you can give feedback on this service.

9 March 2022

During an inspection looking at part of the service

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

11 February 2021

During an inspection looking at part of the service

This practice is rated as Good overall.

At the previous inspections in November 2019 and August 2015 the practice was rated as Outstanding overall. Our inspection in August 2016 was not rated.

We carried out an unannounced focused inspection at Thistlemoor Road Surgery on 11 February 2021. We decided to undertake this inspection following concerns we had received.

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services well-led? – Good

We did not inspect caring and responsive services because monitoring and our findings did not indicate a change since the last inspection. The ratings from the last inspection have been carried forward.

Are services caring? – Good

Are services responsive? – Outstanding

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this unannounced inspection. We therefore undertook some of the inspection processes remotely and spent less time on site. We used a suite of remote searches which were added to the practice clinical system. To ensure we gathered staff feedback we used a questionnaire which was given to staff both electronically via email and 20 questionnaires were given out in paper form.

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.
  • Information from the provider, patients, the public and other organisations.

At our inspection in November 2019 the practice was rated as good for providing safe services.

At this inspection, the practice was rated as requires improvement for providing safe services because;

  • We identified the practice had not undertaken all recruitment checks for new staff in a timely manner.
  • We found not all emergency medicines were easily available.
  • The system to monitor safety alerts had not ensured that all learning from the alerts had been fully incorporated into good practice.
  • There had been a lack of formal clinical oversight in the supervision and review of all health professionals to whom clinical work had been delegated.

At this inspection, the practice was rated as good for providing effective services.

At this inspection, we did not inspect the practice providing caring services and therefore they remain rated as good.

At this inspection, we did not inspect the practice providing responsive services and therefore they remain rated as outstanding.


At our inspection in November 2019 we rated the practice as outstanding for providing well-led services.

At this inspection we have rated the practice as good for providing well-led services because;

  • 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 unannounced inspection, they needed to be embedded and monitored to ensure they would be sustained.
  • The practice demonstrated leadership with clear roles, responsibilities and values. From our staff questionnaires most staff answered positively about the leadership and support given.
  • The practice had a strong culture of learning and development and encouraged staff to undertake further learning and training to increase the skill mix within the practice and provide enhanced services to patients. Some staff found their contractual arrangement restrictive.
  • The practice had been proactive during the COVID-19 pandemic, they were providing the COVID-19 vaccination clinics for their patients and those of other local practices. The staff had been proactive in giving education talks about COVID-19, prevention measures and encouraging uptake of the vaccination.
  • The practice leadership team continually assessed and responded to patients’ needs within their population group and had developed a system of care which met the needs of the population. They employed staff who were able to provide care and support to their patients in the patient’s own first language.
  • The practice and leaders were involved in many initiatives and projects both locally and nationally, supporting the standard of care provided to patients from areas of high deprivation sharing good practice and encouraging improvements. This was in addition to being nominated for national awards recognising the quality of care provided.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review and improve the uptake of cancer screening.
  • Review and improve the uptake of childhood immunisations.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

19 Sept 2019

During an inspection looking at part of the service

This practice is rated as Outstanding overall. At the previous inspection in August 2016 the practice was rated as Outstanding overall.

We carried out an announced focused inspection at Thistlemoor Road Surgery on 19 September 2019. We decided to undertake this inspection following our annual review of the information available to us.

The key questions at this inspection are rated as:

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? – Outstanding

Safe was not reviewed because monitoring indicated no change since the last inspection. The rating from the last inspection has been carried forward.

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.
  • Information from the provider, patients, the public and other organisations.

At this inspection, the practice was rated as good for providing effective services.

At this inspection, the practice was rated as good for providing caring services.

At this inspection, the practice was rated as outstanding for providing responsive services because:

  • Patient’s individual needs and preferences were central to the delivery of tailored services. The practice had developed services in response to their patient population and could evidence positive outcomes resulting in those services.
  • There was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs, which was accessible and promoted equality.
  • The practice provided innovative approaches to providing integrated person-centred care which ensured all patients, including those most vulnerable, received good quality care in a timely manner.
  • Feedback from patients through comment cards, reviews on NHS Choices, the GP National Patient Survey and patient consultations on the day of the inspection were overwhelming positive in relation to the services offered by the practice and the ease of accessing those services.

At this inspection, the practice was rated as outstanding for providing well-led services because:

  • The practice demonstrated strong leadership with clear roles, responsibilities and values. Staff we spoke with commented on how the strong leadership team provided clear direction and guidance and this was reflective of the most recent staff survey.
  • The practice had a strong culture of learning and development and encouraged staff to undertake further learning and training to increase the skill mix within the practice and provide enhanced services to patients.
  • The practice leadership team continually assessed and responded to patients’ needs within their population group and had developed a system of care which met the needs of the local diverse population.
  • The practice had been involved in a number of initiatives and projects both locally and nationally, supporting the standard of care provided to patients and sharing best practice.

The areas where the provider should make improvements are:

  • Review and improve the uptake of cancer screening.
  • Review and improve the uptake of childhood immunisations.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

1 August 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This was the second comprehensive inspection that we had carried out at Thistlemoor Medical Practice

On 3 September 2015, we carried out a focused inspection of Thistlemoor medical practice. The practice was rated as outstanding overall and rated as outstanding for providing effective, responsive, and well led services and good for providing safe and caring services.

Since our previous inspection the Care Quality Commission received reports from anonymous sources relating to the safe and effective care of patients at the practice.

We carried out a short notice announced comprehensive inspection at Thistlemoor Medical practice on 1 August 2016. Prior to the on-site inspection, all staff members were provided with the direct mobile telephone number of the lead inspector. The inspector was available from 8am to 9pm on Friday 29 July 2016 and from 10am to 6pm Sunday 31 July 2016. This gave all staff the opportunity to speak directly with the inspector at a time and a place that was convenient to them. We focused our inspection on the safe and effective domains.

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 well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge, and experience to deliver effective care and treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The training and education systems in place were robust and competency assessment undertaken and evidenced appropriately.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thistlemoor Surgery on 3 September 2015. Overall the practice is rated as outstanding.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • The practice was actively involved in local and national initiatives to enhance the care offered to patients. They were proactive in trialling new ways of working to ensure they continued to meet the needs of the patients.
  • Patients said they were treated in a way that they liked and they were involved in their care and decisions about their treatment. Information was provided in a range of formats and languages to help patients understand the care available to them.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG). Information about how to complain was available and easy to understand.
  • There was a structured system for providing staff in all roles with annual appraisals of their work and planning their training needs.
  • The practice undertook a wide range of both clinical and non clinical audits to drive improvements in patient care.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice had a clear vision that had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice including:

  • The practice offered a wide range of extended hour opening times, both early in the morning, the early evening and on Saturday mornings. The practice operated a walk in surgery each morning which meant that patients who attended between 8.30am and 10.30am were seen. Patients we spoke with particularly valued this walk-in service.
  • Health care assistants were key members of the practice team and most spoke a range of languages, including those spoken by many of the practice’s population group. This supported good communication and patients’ involvement in understanding and managing their care.
  • The practice offered health checks for 40-75 year olds. Despite already meeting its target to complete 300 of these for the year 2015-2016, it had decided to continue with these checks so that patients’ health and well-being could be monitored.
  • The practice offered smoking cessation clinics in different languages to meet the needs of its patients, many of whom did not have English as their first language. These clinics had been successful in helping 70% of those who had attended to give up smoking (56 patients in total).
  • The practice’s premises provided excellent facilities for patients. There was a resource room containing a range of health information for patients; a prayer room for use by both staff and patients; a room for mothers to breast feed their babies in private and two sound proof rooms where staff could telephone patients confidentially and without distraction.
  • A local councillor told us that the practice was very engaged with local schools, inviting school parties to visit and talking to children about the work of doctors and nurses.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 September 2014

During a routine inspection

Thistlemoor Road Surgery provides a primary health care service for approximately 15,000 patients. At the time of our inspection, there were three partner GPs. They employed five salaried GPs. A trainee GP and a junior doctor undertaking foundation training were completing placements there. There were four nurses; 11 health care assistants (HCAs) and a team of administrators and receptionists. Health visitors and district nurses are located within the practice building and other healthcare staff hold clinics there.

We checked to see if services were safe, effective, caring, responsive and well-led. We found that Thistlemoor Road Surgery met all of these criteria. We looked at how the practice provided services for patients who were aged over 75; for patients with long-term conditions; for mothers, babies, children and young people; for patients of working age and those recently retired; for patients in vulnerable circumstances who may have poor access to primary care and for patients experiencing poor mental health. We found evidence of positive care for patients in each of these groups.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.