Background to this inspection
Updated
25 October 2023
Bretton Medical Practice is located in the town of Peterborough Rightwell East Bretton Peterborough Cambridgeshire PE3 8DT.
The provider is registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury, family planning and surgical procedures.
Bretton Medical Practice was previously part of a large GP practice under a different provider that worked at scale. Bretton Park Healthcare, the new provider, registered with the Commission in January 2022 and has another GP practice, Bretton Medical Practice.
The practice offers services from both a main practice and a second location, Park Medical Centre which was inspected separately.
The practice is situated within the Cambridge and Peterborough Integrated Care System (ICS) and delivers General Medical Services (GMS). This is part of a contract held with NHS England. Bretton Medical Practice has a list size of 12,079 patients.
Due to the practice being de-merged from a larger practice group at the time of this inspection there was no information published by Office for Health Improvement and Disparities to show the deprivation within the practice population group.
The practice provided information regarding their population.
The index of deprivation decile is 2, where 1 is the most deprived and 10 is the least deprived. The ethnic make-up of the practice area is, 72.6% White, 14.5% Asian, 7.2% Black, 3.4% Mixed, and 2.3% Other.
Bretton Medical Practice is a teaching practice and there are 4 GP registrars in post.
The practice is part of a wider network of GP practices, Bretton Park & Hampton Primary Care Network (PCN). There is a team of GPs who work at the practice.
There are 2 GP (male) partners supported by a team of 19 reception/administration staff, 4 healthcare assistants, 3 practice nurses, 3 advanced nurse prescribers and 3 pharmacists. In addition, the practice has salaried part time GP’s (female and male) and uses regular locum GPs.
The practice manager is generally based at the location to provide managerial oversight. The practice is open between 8:00 am to 6:30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Extended access is provided locally by the practice where weekend appointments are available. Out of hours services are provided by NHS 111
Updated
25 October 2023
We carried out an announced comprehensive at Bretton Medical Practice on 16 August 2023. Overall, the practice is rated as good.
Safe - Good.
Effective – Good.
Caring – Good.
Responsive - Requires Improvement.
Well-led – Good.
This was the second inspection of Bretton Medical Practice under the registered provider Bretton Park Healthcare who became the provider in January 2022. Bretton Park Healthcare is the provider of 2 locations, Bretton Medical Practice and Park Medical Practice. We inspected both practices within a 2-day period as both locations were managed by a central team function and both clinical and non-clinical staff worked across both locations. At our previous inspection in November 2022, the practice was rated inadequate.
At this inspection, we found that significant improvements had been made through clear clinical leadership and within the practice. The practice is now rated as good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bretton Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this inspection to follow up concerns and breaches of regulation from a previous inspection.
How we carried out the inspection.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
- Staff questionnaires.
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 found that:
- At our last inspection November 2022, we found significant concerns and poor governance systems relating to the services delivered to patients. At this inspection we found the practice had made improvements.
- The leadership team had engaged with the Integrated Care Board and experienced external managers to develop a comprehensive action plan. The team had implemented new systems and processes to ensure services were delivered in a safe and effective way to patients. There were systems and processes in place to regularly review and monitor all actions/improvements.
- 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.
- The GP partners had addiotnal protect time to ensure the overall governance arrangements and processes for managing risks, issues and performance were reviewed regularly and were effective. Staff told us there were more meetings that they were invited to and that their well-being was considered.
- There was low patient satisfaction regarding appointments access and we noted they could not always access care and treatment in a timely way. We saw that the practice offered a range of appointments including extended and weekend appointments, some of which took place at the practice.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
Whilst we found no breaches of regulations, the provider should:
- Continue to monitor and improve the coding of medical records to provide accurate information within the medical records.
- Continue to encourage patients to attend their appointments for the national cervical cancer screening programme.
- Continue to monitor the new system for annual recalls and reviews to provide patients with appropriate on-going care.
- . Continue to monitor patient feedback to improve patient satisfaction on accessing the practice.
I am taking this service out of special measures and the conditions that were imposed on the provider’s registration will be removed. This recognises the significant improvements that have been made to the quality of care provided by this service.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care