Boroughbury Medical Centre

Updated 31 May 2022

Boroughbury Medical Centre is located in the region of Cambridgeshire and Peterborough at:

Boroughbury Medical Centre

Craig Street

Peterborough

PE1 2EJ

01733 307840

Werrington Surgery (Branch)

97 Church Street

Peterborough

PE4 6QF

01733 307840

Boroughbury Medical Centre is situated in Peterborough, Cambridgeshire in Craig Street and has a branch surgery in Werrington. The practice has a general medical services (GMS) contract with the NHS. There is a branch site approximately 3 miles away called Werrington Surgery, located in Church Street and there are more than 25,000 patients registered at the practice. Patients can choose to be seen at either location and we visited both locations for the purpose of this inspection.

The practice has eight Partner GPs and one Managing Partner, two of whom are the registered managers, six salaried GPs. It is also a teaching practice for GP registrars and medical students. The clinical nurse manager (male) is supported by a Deputy Nurse Manager (Female), Deputy Paramedic Manager (Male) and Deputy Clinical Pharmacist Manager (Male), fifteen practice nurses (14 female and one male), six Paramedic Practitioners (four male and two female), three Clinical Pharmacists (two male and one female), one Pharmacy Technician (female), First Contact Physiotherapists (one female and one male), Social Prescribing Link Worker (one female) and six health care assistants (two male and 4 female) The Managing Partner is supported by a Leadership team comprising of the Clinical Nurse Manager, Business Support Manager, Patients Services Manager and Head of Medicines Management.

There is a team of 39 staff members providing reception, administration, and secretarial services including Team Leaders and Deputy Manager and support the Business Support Manager and Patient Services Manager. A team of ten staff support the Head of medicines management (a non-clinical staff member).

There are members of staff employed who are fluent or conversational in more than 20 different languages including Spanish, Urdu, Hindi, Dutch, Italian, Polish, and Arabic.

The practice is open Monday to Friday between 8am to 6.30pm. Extended hours appointments are offered on three evenings per week and most Saturday mornings. Patients are required to book these appointments in advance. Urgent appointments are also available for people that need them, as well as telephone appointments. The practice is able to offer and book appointments for patients to be seen in the Greater Peterborough Network extended hours service which operates from the practice premises.

When the practice is closed patients are automatically diverted to the GP out of hours service provided by Herts Urgent Care. Patients can also access advice via the NHS 111 service. The practice patient age profile is slightly below national average with the life expectancy of patients below the national average.

The deprivation score is above the England average indicating that the practice serves a deprived area. We reviewed the most recent data available to us from Public Health England which showed the practice has a slightly larger number of patients aged 65 to 75 compared with the national average. It has got a larger number of patients aged 75 to 85 compared to the national average

Updated 31 May 2022

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