The Care Quality Commission
  • Doctor
  • GP practice

Boroughbury Medical Centre

Overall: Outstanding read more about inspection ratings

Craig Street, Peterborough, Cambridgeshire, PE1 2EJ (01733) 307840

Provided and run by:
Boroughbury Medical Centre

All Inspections

29 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at Boroughbury Medical Practice on 29 March 2022. We visited the main surgery at Craig Street in Peterborough and the Werrington Branch in Church Street. Overall the practice is rated Outstanding.

The ratings for each key question were:

Safe - Good

Effective - Good

Caring - Good

Responsive - Outstanding

Well-led - Outstanding

The practice was previously rated Good in February 2018.

We undertook this full comprehensive inspection on 29 March 2022 and the practice was found to be Good overall.

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

Why we carried out this inspection

This was a comprehensive inspection 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 this inspection included :

  • Key questions inspected including Safe, Effective, Caring, Responsive and Well led.
  • Additional questions in relation to urgent and emergency care.

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 facilities
  • 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:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs, specifically those in hard to reach communities such as homeless people and others who would not normally consider their needs as a priority.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The mission statement of the practice was “To provide professional, accessible, high quality, comprehensive healthcare services that inspired confidence in the patients and the community”. We were told that practice leads were continually assessing and responding to patients needs and had improved their services taking into account the most vulnerable patients as priority. We saw evidence of that on the day of the inspection.

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

  • Patients’ individual needs and preferences were central to the delivery of services and specifically tackled health inequalities particularly for hard to reach groups of patients, such as homeless people and other people who would not normally consider their health needs as a priority.
  • 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, specifically those most vulnerable were encouraged to engage and received good quality care in a timely manner. The practice was involved in many pilot schemes throughout the community to encourage better self-care in vulnerable people.
  • Evidence of positive outcomes for those patients was demonstrated through feedback from partner organisations and also during discussion on the day of the inspection.
  • The practice had been nominated for awards (for example by the Health Service Journal), and received funding to continue their work with the homeless and vulnerable patients in the community.

We rated the provider Outstanding for providing Well Led services. We found that:

  • Leaders were inspiring, and motivated and encouraged staff to succeed. There were high levels of satisfaction across all staff. There was a strong organisational commitment towards quality and inclusion across the patient population and the workforce.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. At all levels they were actively encouraged to speak up and raise concerns. We observed strong team working.
  • Governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with other organisations to improve care outcomes.
  • The practice invested in innovative and best practice information systems and processes. There was a demonstrated commitment at all levels to sharing data and information proactively to drive and support internal decision making as well as system-wide working and improvement
  • Improvement was seen as the way to deal with performance and for the organisation to learn. Improvement methods and skills were used across the organisation, and staff were empowered to lead and deliver change.

The practice should:

  • Risk assess and review that due diligence has been undertaken on members of staff who are deemed not to require a DBS check.
  • Risk assess where sharps bins are not wall mounted.
  • Undertake a review of staff immunisation status.
  • Take action to improve child immunisation and cervical screening scores.

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

28 February 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at the Boroughbury Medical Centre on 23 November 2017. The practice was rated as good for providing effective, caring, responsive and well led services and requires improvement for providing safe services. Overall the practice was rated as good. The full comprehensive report following the inspection on 23 November 2017 can be found by selecting the ‘all reports’ link for Boroughbury Medical Centre on our website at www.cqc.org.uk.

We undertook a desk based review of Boroughbury Medical Centre on 28 February 2018. This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements.

Overall the practice is still rated as good, and has been rated as good for providing safe services.

Our key findings were as follows:

  • The practice had discussed the findings from the previous inspection with the nursing team and had developed a team approach to implementing and embedding the improvements required.
  • The practice had ensured that refrigerators where medicines could be stored were maintained and monitored safely.
  • The practice had implemented systems and processes to ensure the temperatures of the fridges were always recorded and that the actions taken if the temperatures went out of the recommend range were recorded.
  • The practice had implemented cleaning schedules to ensure that all the refrigerators met the required standard for cleanliness.
  • The practice undertook unannounced spot checks to ensure the new systems and processes were being met.
  • We saw evidence that the refrigerators had been serviced and a contract was in place to ensure that this was regularly undertaken to ensure they were working properly.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

23 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as good overall. (Previous inspection May 2016 – Good)

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? - Good

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 – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those retired and students – Good

People whose circumstances may make them vulnerable – Good

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

We carried out an announced comprehensive inspection at Boroughbury Medical Centre

on the 23 November 2017 as part of our regulatory functions.

At this inspection we found:

  • The practice had developed and embedded a clear and comprehensive system to ensure that meetings were held and were inclusive of all practice staff, detailed minutes were shared to ensure actions were taken, risks mitigated and learning was shared.
  • 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.
  • The practice had systems and processes to manage and mitigate risks to patients and staff such as fire safety. However, the practice system and process to ensure that refrigerators used to store medicines were at the correct temperatures and suitable for use needed to be improved. Immediately following our inspection, the practice took actions to ensure temperature records were kept and cleaning schedules were implemented.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Care and treatment was always delivered according to evidence- based guidelines.
  • The leadership, governance, and culture were used to drive and improve the delivery of high-quality person-centred care. Staff felt involved in the development of the practice and was proud of the practice.
  • The practice recognised a higher rate of children not attending their appointments for the immunisation clinics and had adjusted the clinic times to encourage uptake.
  • Staff involved and treated patients with compassion, kindness, dignity, and respect.
  • The National GP survey data showed that the practice was significantly below the local and national averages in some areas. They had responded to poor survey and patient feedback in relation to delays in making appointments. They had invested and implemented a 24 hour, seven day a week automated appointment system and increased the skill mix available and had employed additional staff such as a nurse practitioner and primary care practitioners.
  • The practice had been proactive and had increased the uptake for flu immunisation significantly from the previous year.
  • We saw several areas of innovation and service development and improvement which were a priority amongst staff and leaders.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice engaged with the PPG and local communities. They support local national and international charities by raising money and awareness.

We saw one area of outstanding practice:

  • The practice had engaged and promoted a community approach to their care of patients. A GP partner worked alongside the citizen advice bureau and developed a direct referral system so that the vulnerable patients from the practice had easy access to volunteer and support groups including housing, financial advice, drug, and alcohol issues. The practice had employed a staff member to undertake the role of a community liaison champion. This champion ran weekly groups, held in the practice which included a new parent group, carers group, over 65 coffee mornings and a healthy minds group. Feedback from patients we spoke with told us that they found the coffee morning very valuable and enjoyable and a good place to gain information and support. The practice had received recognition for the high number of referrals to the carer’s support group and was active in supporting local, national, and international charities. Monies raised by staff were matched by the partnership. Charities that had been supported included the local women’s refuge, children in need, and the shoe box appeal that sends aid to other countries.

The area where the provider must make improvements as they are in breach of regulations is:

  • Care and treatment must be provided in a safe way for service users.

The areas where the provider should make improvements are:

  • Continue to assess and ensure improvement to national GP patient survey results relating to patient satisfaction.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

24 May 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at Boroughbury Medical Centre on 24 May 2016. Overall the practice is rated as good. We had identified a number of shortfalls at our previous inspection in January 2015 and issued three requirement notices under the Health and Social Care Act 2008 as a result. During this inspection, we found that the practice had taken sufficient action to address the breaches in regulations.

  • The practice had continued to improve telephone access and had trialled using different telephone lines. They had proactively sought patient feedback on this issue, and the patients we spoke with generally made positive comments about booking an appointment.
  • Infection prevention and control procedures had been formalised at both the main site and branch surgery. Cleaning schedules and monitoring systems were more robust, and we saw evidence of staff undertaking appropriate training.
  • Access to emergency equipment on different floors of the building had improved, and we saw evidence of a comprehensive monitoring system of stock held in the emergency trolley.
  • Complaints and significant events were analysed more closely and discussed with different members of staff at regular practice meetings.
  • Governance systems were more robust. The practice had implemented an online system which held a comprehensive list of policies and procedures that were relevant to practice, along with personnel information and training schedules for staff.
  • Data showed that the practice had made significant progress on medication reviews for patients who were prescribed medicines that require specific monitoring. The practice had a plan in place to ensure that the system for recalling patients continued to improve.
  • The practice provided health promotion information in appropriate languages and formats. Furthermore, the practice had implemented a multi-faith calendar and an administration apprentice had taken on the role of ensuring that the practice showed an awareness of different religious events throughout the year. 
  • The practice had formulated a clear audit plan which demonstrated future quality improvement. Five clinical audits had been undertaken since the previous inspection.
  • A fire drill had been undertaken in line with the practice fire risk assessment. Other practice risk assessments were robust and were scheduled to have timely reviews.
  • The practice had implemented safeguarding registers for adults and children.
  • Staff we spoke to on the day of inspection felt that there had been good progress made within all areas of the practice. 

The areas where the provider should make improvements are:

  • Review the process for cascading Medicines and Healthcare Products Regulatory Agency (MHRA) updates throughout the practice.
  • Continue to improve the recall system for medication reviews for patients who are prescribed medicines that require specific monitoring.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boroughbury Medical Centre on 12 January 2016. Boroughbury Medical Centre is a new service which was merged from two former practices in November 2015. Overall the practice is rated as requires improvement.

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

  • Patients said they were treated with compassion, dignity and respect, and that they were involved in their care and decisions about their treatment.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Complaints were responded to satisfactorily, but no learning had been identified from them at present.

  • The practice had a proactive approach to learning and development, and had an on site library and dedicated teaching space for trainees and students.

  • The practice had good relationships with the multidisciplinary team. The building had designated rooms for midwives, health visitors and a mental health support worker who held weekly clinics in the practice.

  • Urgent appointments were usually available on the day they were requested. However, patients found that the system was not responsive and there were significant delays in getting through to reception staff.

  • Because the practice was new, it was too early to see clinical audit taking place and being used to develop performance and improve patient outcomes.

  • Information about services was available in the waiting areas but not everybody would be able to understand or access it. For example, all information in the waiting area was in English, despite there being a large number of patients who did not speak English on the practice list.

  • The practice told us that they held regular clinical meetings, however there were no meeting minutes available for us to see. 

  • The practice had a number of policies and procedures to govern activity.

  • Daily cleaning logs were not consistently completed. We found that disposable curtains used at the branch surgery were not changed as regularly as required.

  • Newly appointed staff had been subject to appropriate recruitment checks. However, a number of other personnel files were incomplete.

  • The practice did not have a robust system in place to check that the needles and syringes in emergency trolleys were in date. The emergency trolley was on the ground floor, and there was no evidence that a risk assessment had been undertaken to assess the risk within the large, three storey building.

  • Data showed that the practice did not have robust medication review systems in place to monitor drugs that require monitoring.

  • Staff had designated lead roles, however not all members of staff were aware of these.

The areas where the provider must make improvements are:

  • Implement and embed the required improvements to ensure that patients can make appointments in a timely way.

  • Ensure that patients who are prescribed medicines that require specific monitoring are reviewed in line with national prescribing guidance.

  • Ensure that emergency drugs and medical equipment are in date and are easily accessible to all staff throughout the building.

  • Premises and equipment must be kept clean in line with current legislation and guidance. This includes operating a cleaning schedule, monitoring levels of cleanliness and ensuring that staff with responsibility for cleaning have appropriate training.

  • Develop specific safeguarding registers for vulnerable adults and children.

In addition, the provider should:

  • Ensure that there are different sized chairs available in the waiting areas.
  • Provide practice and health education information in appropriate languages and formats.
  • Formulate a clear audit plan to demonstrate future quality improvement.
  • Deliver a programme of clinical audits to improve patient outcomes.
  • Share the learning outcomes from complaints with staff.
  • Implement a system for maintaining stock control of medicines used in the practice.
  • Review staff personnel files to ensure that key information is held.
  • Ensure that regular fire drills are undertaken in order to safeguard patients and staff.

Where a practice is rated as inadequate for one of the five key questions or one of the six population groups the practice will be re-inspected within six months after the report is published. If, after re-inspection, the practice has failed to make sufficient improvement, and is still rated as inadequate for any key question or population group, we will place the practice into special measures. Being placed into special measures represents a decision by CQC that a practice has to improve within six months to avoid CQC taking steps to cancel the provider’s registration.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice