Statement of purpose and infection control
Statement of purpose (as of July 2019)
The name and address of the registered provider is:
Thistlemoor Medical Centre
6-10 Thistlemoor Road
Registered Manager: Dr. Neil Modha
Practice Manager: Ms. Paulina Janczura
Legal Status: Partnership
Service Types:Doctors Consultation Service
Doctors Treatment Service
Treatment of disease, disorder or injury
Diagnostic and Screening Procedures
Maternity and Midwifery
Family Planning Service
Open for Registration to patients resident and temporarily resident on the practice area.
The surgery has existed for over 50 years and started as a single building. The practice has been completely remodelled over its history to now consist of purpose built facility within modern premises. The practice also has large onsite parking. We have been a training practice since 2010.
Under the Health and Social Care Act 2008 (The Care Quality Commission (Registration) Regulations 2009 Part 4), the registering body (Thistlemoor Medical Centre) is required to provide to the Care Quality Commission a statement of purpose.
Our Aims and objectives:
• Provide a high standard of Medical Care
• Be committed to our patients needs
• Act with integrity and complete confidentiality
• Be courteous, approachable, friendly and accommodating
• Ensure safe and effective services and environment
• To maintain our motivated and skilled work teams
• Through monitoring and auditing continue to improve our healthcare services
• Maintain high quality of care through continuous learning and training
• Ensure effective and robust information governance systems
• Treat all patients and staff with dignity, respect and honesty
• Ensure that every individual is treated fairly and without discrimination
Our purpose is to provide people registered with the practice with personal
health care of high quality and to seek continuous improvement on the health
status of the Practice population overall. We aim to achieve this by developing and
maintaining a happy sound Practice which is responsive to people’s needs and
expectations and which reflects whenever possible the latest advances in Primary
The Primary Health Care Team
Dr Nalini Modha, GP trainer, Senior Partner
Dr Jitendra Modha
Dr Neil Modha, GP Trainer
BSc (hons) Healthcare management
Dr Azhar Chaudhry, GP Trainer
Dr Karen Hamilton,
Dr Mehr Ahmed,
Dr Catherine Jones,
Dr Jessica Randall-Carick
Dr Emma Hamilton
Dr Lubna Salim
Dr Muhammed Mukhtar
Dr Taiwo Olufemi
Dr Lubna Akbar
Community Staff (Nurses, Pharmacists and Paramedic)
The practice nurses work to manage chronic disease conditions to empower our patients. They run smear, baby immunisation and health promotion clinics.
Ajmal Razza (lead)
Health Care Assistants
Healthcare assistants have appointment sessions for venepuncture, blood pressure and pulse measurements, as well as ECGs, healthy living screening and ear syringing. They help the clinical team as physicians assistants and work alongside the nursing team. They also conduct home visits for those patients unable to access the Practice for patients with long term conditions. The HCAs have a diverse set of training including smoking cessation clinics.
Ms Paulina Janzcura
Paulina has the responsibility for ensuring the smooth running of the Practice on a day-to-day basis. She is supported by Dr Nalini Modha who works as a clinical manager. She has completed postgraduate training and has an MBA as well as a degree in Health and Social Care.
The Reception team man the Practice Reception areas in the Health Centre, arrange various appointments, produce patient repeat prescriptions, pass on information to patients, explain our services and answer the telephone lines.
The Secretaries are able to answer patient enquiries concerning communications between the
Practice and other agencies, e.g. Hospitals.
The Clinical Administrative team is responsible for updating and summarising patients’ medical records, for organising the appointment system on the computer and operating a recall system for patients when appropriate.
Each team has a full knowledge of the services the Practice has to offer.
All members of the staff are happy to assist you with any enquiries.
The Doctors will make home visits for those patients unable to come to the Practice. In order for these visits to be made promptly, we ask that requests for this service are made before 10-11.00am. We ask that wherever possible patients attend the Surgery. This speeds up being seen by the Doctor and provides better facilities for treatment.
Out of Hours
Out of hours care is provided in Peterborough - please phone - 01733 293838 to speak to the service.
This will be daily from 18:30 - 0800 am (Monday to Friday) all day (Saturday, Sunday and Bank Holidays)
NHS 111 Service
NHS 111 – a medical telephone service - is available in Cambridgeshire and Peterborough.
NHS 111 has been introduced to help make it easier for residents to access local health services, advice and information. People living in Cambridgeshire and Peterborough can now call 111 when in need of medical help fast, but it isn’t a 999 emergency. 111 is available 24 hours a day, 7 days a week, 365 days a year and calls from landlines and mobile phones are free.
The 111 service is being provided by Herts Urgent Care, an organisation that has a proven track record in providing the 111 service elsewhere.
Calls to 111 are recorded. All calls and the records created are maintained securely, and will only be shared with others directly involved with your care.
The practice runs open-access surgeries where by any patient registered at the Practice will be seen by the Practice team Monday to Friday 8:30am to 10:30am. Patients will be asked for their preferred clinician and where possible they will see this clinician. If this clinician becomes fully booked we will offer an alternative clinician. We pride ourselves with offering appointments on the same day, but this can lead to very busy surgeries and waiting times can increase on such days. Patient choice of clinicians may be restricted at busy times like the days around weekends and bank holidays to try to improve the efficiency of the practice.
The afternoon clinics are pre-bookable and can be accessed by phone or in person. The clinicians often have review slots booked in before and after morning surgeries.
Our aim is that prescription requests will be dealt with within two working days.
Requests can be made using the right-hand, white side of the last prescription issued and dropping it into the box in the foyer. Patients are asked to make certain they tick the medication they require. A prescription order form from Reception can also be used if the original white side is not available. Requests can also be made by post, posting it to us with an enclosed stamped addressed envelope if we are to post it back.
Local Pharmacies also provide an ordering and collection service.
Our patients are now also able to order repeat medication through our website.
The Regulated Activities under CQC
General medical services and routine medical checks involving an holistic approach.
Management of Chronic Disease
This encompasses a wide range of conditions which require long term treatment and care. Our
priority is to ensure this care is ongoing and appropriate. To this end, we shall endeavour to review
patients’ medication on an annual basis. Diabetic, Stroke, CHD and Asthma reviews are regularly
performed in the Practice as required throughout the year and in accordance with NICE guidelines.
General Nursing Care
Our nurses provide wound care, contraceptive services, minor illness care and advice, smoking cessation advice, well person checks, new patient checks, venepuncture, blood pressure monitoring and travel advice; they also perform vaccinations, ear syringing and smear tests.
Midwife clinics are held daily for our patients. The local hospital maternity department provides this service with community midwives.
This service is provided by our Practice Nurses who are trained in cytology.
Family Planning and Contraceptive Services
This is provided by Doctors and Nurses. Nurses are able to provide follow-up contraception monitoring for all methods initiated by the Doctor. We provide an implant service or the insertion of coils and implants.
We also carry out testing for Chlamydia where appropriate.
Vaccinations and Immunisations
Thistlemoor Medical Centre strongly supports the childhood immunisation programme. Our Practice Nurse Team following an automatic invitation from the Local Health Authority performs all routine childhood immunisations at the surgery.
The Practice also offers vaccinations for young adults against measles if they are not protected.
Vaccination against whooping cough is offered to pregnant women and new mothers.
The Practice offers all ‘at risk’ patients and those over 65 the seasonal influenza vaccine from September to January every year and also vaccination against pneumonia. This is managed by call-recall.
Foreign Travel Health Advice
Our nurses have been trained to provide an up-to-date service however will sign post you to other services for the vaccinations (please note that there is a charge for most travel vaccinations).
Well Person Checks and NHS Health Checks
These are carried out by the Practice Nurses and the Health Care Assistants.
Therapeutic joint injections are carried out by Dr Neil Modha, Dr Karen Hamilton and Dr Azhar Chaudhry.
Minor Surgical procedures are carried out by Dr Azhar Chaudhry, Dr Neil Modha and Dr Karen Hamilton
Access to Patient Information
All patient information is considered to be confidential and we comply fully with the Data Protection Act. All employees have access to this information in relation to their role and have signed a confidentiality agreement. Information may be shared, in confidence, with other NHS organisations in the interests of patient care.
Confidential patient data will be shared within the healthcare team at the Practice and with other healthcare professionals to whom a patient is referred. Those individuals have a professional and contractual duty of confidentiality.
Confidential and identifiable information relating to patients will not be disclosed to other individuals without their explicit consent, unless it is a matter of life and death or there is a serious risk to the health and safety of the patient or it is overwhelmingly in the public interest to do so.
In these circumstances the minimum identifiable information that is necessary to serve a legal purpose may be revealed to another individual who has a legal requirement to access the data for the given purpose. That individual will also have a professional and/or contractual duty of confidentiality. Data will otherwise be anonymised if possible before disclosure if this would serve the purpose for which it is required.
The Practice Caldicott Guardian is Dr. Nalini Modha.
Patients Rights and Responsibilities
Patients have a right to expect a high standard of care from our Practice and we will try at all times to provide the very best care possible within the resources available.
In order to assist us in this we require that patients take full responsibility for ensuring that they do not abuse the service. For example, it is the patient’s responsibility to ensure that they keep medical appointments and follow the medical advice given. In addition, if a medical problem is complicated, or patients have more than one problem to discuss with the Doctor, we would suggest that patients consider making more than one appointment. We ask patients to remember that their appointment is for them alone and the Doctor will not be able to give medical advice to anyone accompanying them unless they have made a separate appointment.
Very occasionally a Practice/Patient relationship breaks down completely. In the event of an eventual breakdown, the patient may then choose to register with a different Practice. The Practice also has the right to remove that patient from their list. This would only follow warnings that had failed to remedy the situation and we would normally give the patient a specific reason for the removal.
You have the right to express a preference of practitioner when you make an appointment.
Violent Patients – Zero Tolerance
The NHS operates a Zero Tolerance Policy with regard to violence and abuse and the Practice has the right to remove violent patients from the list with immediate effect in order to safeguard Practice staff, patients and other persons.
Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety.
In this situation we are obliged to notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and circumstances leading to it.
We will notify the Area Team who is then responsible for providing further medical care for such patients.
Comments, Suggestions and Complaints
We welcome comments and suggestions on our service. We provide a leaflet in Reception entitled “Compliments and Complaints” to make it easy for patients to contact us. If we fail to provide the highest care possible, we ask that any observations are made known to our deputy Practice Manager who will, where appropriate, use our complaints procedure to try to correct the problem.
Our complaints procedure meets national criteria and patients can obtain a copy of it from Reception. We aim to acknowledge a complaint within 3 working days and look into it within 10 working days of the date that it’s raised. We will find out what happened and what went wrong, make it possible for the patient to discuss the problem with those concerned if they would like this, make sure the patient receives an apology where this is appropriate and identify what we can do to make sure the problem does not happen again. If a patient is still unhappy about the response, they also have the right to take the matter to the Ombudsman within 12 months.
Access to Health Records
The Data Protection Act allows patients to find out what information is held on computer. This applies to health records. If a patient wishes to see them, we ask that they make a written request to the Practice. Patients are entitled to receive a copy, but should note that a charge may be made.
A carer is someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour who could not manage without their help. This could be due to age, physical or mental illness, substance misuse or disability. Anyone can become a carer. Carers come from all walks of life, all cultures and can be of any age.
We ask that patients inform our Reception or clinical staff if they are a carer or are cared for by another person. This will alert us to possible needs in this role.
Change of personal details
Patients are asked to notify the Practice as soon as possible of any change of name, address or telephone number; not forgetting to indicate all the persons involved in this change. In an emergency this could be absolutely vital. You can do this in person, by post or online through our website.
If a patient requests that a chaperone is present at a consultation or procedure, we will arrange for our Health Care Assistant to be present during the examination.
We ask patients for personal information in order that they receive appropriate care and treatment. This information is recorded on a computer; consequently, we are registered under the Data Protection Act.
The Practice will ensure that patient confidentiality is maintained at all times, by all members of the Practice team. However, for the effective functioning of a multi-disciplinary team, which is what we are, it is sometimes necessary that medical information is shared with other members of the team.
Because Reception is sited in a public area, we will provide a separate interview room if a patient needs some privacy to discuss something with us. This can be requested at Reception at the time it is needed.
Patient Participation Group
Thistlemoor Medical Centre is committed to continually improve our services by learning from and listening to our patients.
We have a Patient Participation Group who we contact online through e-mails and in person. Any registered patient is invited to join this group through the Practice website or discussion with Paulina Janczura.
Thistlemoor Medical Centre Statement of Purpose
Date: May 2019
Review Date May 2020
Signed by Registered Manager_____Dr Neil Modha________
Annual Statement of Infection Control: 2019-2020
Infection Control Annual Statement 2019-20
An annual statement is generated each year in April. The next annual Statement is due in April 2020.
The aim of this statement is to provide an update since last statement which includes further evidence in the following topics:
• Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Events Reporting procedures).
• Details of any infection control audits undertaken and actions taken.
• Details of any infection control risk assessments undertaken.
• Details of staff training.
• Any review and update of policies, procedures and guidelines.
The infection prevention and control Clinical lead for Thistlemoor Medical Centre is
Dr Nalini Modha and Lead Nurses are Kanize Panjwani and Paul Watson.
The Administrative leads are: Robertas Grabauskas, Joanna Kondek, Rachana Khatri and Monika Klosowicz.
* Paul Watson and Kanize Panjwani Nursing Leads took responsibility in February 2019 from Ana Castro for Infection Prevention and Control when Ana Castro returned to her Country of origin.
There have been no significant events raised that are related to infection control since the annual statement.
Significant events documentation is kept and reviewed by Paulina Janczura/ Robertas Grabauskas.
All significant events documentation are reviewed and discussed in clinical meetings and Practice Meetings with all staff regularly.
The main team responsibility for completed and up to date audits is Monika K and Paulina P supported by Robertas Grabauskas and Rachana Khathri.
The purpose of the audits was to establish whether all clinicians were disposing of clinical waste products in accordance with statutory regulations and also to re-assess the position of sharps boxes, ensuring that they were not accessible to children.
All sharps box locations were found to be appropriate and safe and did not require relocation. Some Consulting and treatment rooms were improved in order to guarantee all hooks were effective placed in the walls.
The audits are repeated in three monthly intervals to ensure good practices are kept on a daily basis by all clinicians and staff members.
The audits which involve checking consulting and treatment rooms are completed on a monthly schedule and they have been carried out by Monika K and Paulina P.
Toilets are checked at mid-day after morning surgery and a full cleaning of these premises are performed out of hours daily.
The clinical evidence carried by the responsible members are kept up to date and for reference their folders may be checked.
Risk Assessments and outcomes
Risk Assessments are carried out to ensure that the practice can review potential risks and ensure that steps are taken to minimise the impact of these risks.
Our infection control lead carried out an infection control inspection in January 2019 period when the quarterly internal audit would have taken place.
The following actions were needed:
· Proper cleaning of rooms in some areas with further supervision required:
i. Action Plan: the cleaner’s supervisor - Rachana was to complete and supervise the general audit as per her job specification in the general cleaning process of those areas.
ii. A cleaning meeting with all cleaners and leads took place in March 2019. For reference please see Appendix III – Minutes of the meeting.
iii. Attendees at the meeting were: Joanna K, Rachana K, Monika G, Ilieana Lluc, Gina Mehedintu, Juta and Magda- Ioana
iv. Topics discussed were as follows:
§ General overview of the cleaning areas with the responsible cleaners affected to each one (Appendix IV);
§ Cross-cover during holiday period;
§ Saturday Rota and cleaning duties
§ Cleaning duties when covering for colleagues
§ Cleaner’s stock
§ Cleaning equipment use
§ Cleaning products
§ Legionella Testing
· Hand washing techniques assessment Paul Watson completed training in March 2019
i. Action Plan: training provided to all staff by Ana Castro on the 20th and 22nd of June 2018 and as an update on the 22nd of October 2018 and by Paul Watson in March 2019.
ii. Hand washing trainings took place in April 2019 (half yearly) for new staff and the update for the current staff.
iii. In all room and utilities areas were replaced the Hand wash Hygiene Technique data sheet, as some of them were to be replaced due to poor state of repair.
iv. To all doctors a hand sanitizer was supplied for their visiting bags for home visit.
· Infection Control and Health & Safety Training was provided by Dr Neil Modha and Ana Castro 20th and 22nd of June 2018 and as an update on the 22nd of October 2018. The last training has been provided on 31 January 2019.
i. The following topics discussed at this meeting:
§ Correct use of sharp bins
§ Needlestick injury prevention and management
§ Infection control common risks
§ Infection control- looking after each consulting room
§ Review of the Infection Control Policy
· Legionella Risk Assessment was done on the 21st of September 2017 and its next inspection is due to be in September 2019. For evidence and reference the physical folder is ought to be consulted with Robertas Gabrauskas. All recommendations are in place and working fully.
i. Action Plan: a meeting with Robertas to check the full documentation was in place in December 2017. Legionella Policy has been reviewed in September 2018. The next review is planned in September 2019.
· Regarding Waste Management, An audit was undertaken and training took place, as some of the waste was not separated correctly to comply with recycling requirements and a demonstration was provided for assembly of Sharp bins and correct colour coding for disposal of sharps contaminated with only blood, with medication and with cytotoxic medication .
i. Action Plan: training provided to all staff by Ana Castro on the 20th, on 22nd of June 2018, on the 22nd of October 2018 and as an update on 31st January 2019 . The last training was provided by Paul Watson in March 2019. /training dates from Paul Watson/
ii. Maintaining the cold chain-receiving, storing and handling of vaccines, ordering maintaining stock and rotating vaccines.
iii. A meeting with cleaners took place on the 15th of June 2018 to ensure that all cleaners are aware of the waste protocol. The last meeting for cleaners was in March 2019. / Rachana to complete/check/
· A General Cleaners Meeting took place on the 20th of March 2019 with the presence of the all cleaners, cleaning Admin staff: Rachana Khatri and Joanna Kondek and Magda- Ioana for translation. Topics discussed: general overview of cleaning area, rota duties, cleaning product summary, cleaning equipment use. /Rachana to check/ complete/
· A COOSH Assessment was done as well to guarantee the cleaners were aware of the storage arrangements, first aid and PPI (Appendix V).The last risk COOSH Risk Assessment was completed by Ana Castro on 1st February 2019 and the next one is planned in August 2019. The responsible person to complete the next risk assessment is Rachana Khatri.
Staff are up to date with their infection control training delivered by Paul Watson in three meetings:
- Handwashing technique, proper segregation of waste on the 20th and 22nd of June 2018 (Appendix Vi) and as an update on the 22nd of October 2018 (Appendix VII). The last hand washing training was held on 17th April 2019 for new staff and as an update for current staff.
- Infection control, maintaining the cold chain training and an update were carried out on the 20th and 22nd of June 2018. The last update training has been provided in January 2019.
- All training is provided regularly by Clinical Staff and there is a plan for min annual update on training.
The Infection Control training included the following areas:
- Aims of the Infection Control Policy;
- Infection Control in the practice;
- Infections: transmission, standard universal precautions and prevention;
- Maintaining the cold chain;
- Hand washing technique;
- Waste management and types of waste;
- Correct assemble and disposal of yellow sharp bin;
- MRSA: Peterborough City Hospital Protocol and case study.
This training is ought to be provided twice a year to involve all new staff and as an update and refreshment of knowledge and good practices in our surgery.
As there was a case of Needlestick Injury, this theme was discussed as well in the training provided by Ana Castro to all the Healthcare Assistants on the 20th and 22nd of June 2018 and as an update on the 22nd of October 2018.
The last Infection Control Training held on 31st January 2019 included Needlestick Injury training.
PPE (Personal Protective Equipment)
The practice provides PPE for all members of the team in line with their role.
· PPE audits completed by Rachana Khatri in January 2019 were done throughout and quarterly during the period of April 2018 to March 2019 and this will be continue in 2019-2020.
i. Evidence is available for reference in the Infection Control Audit Folder.
Waste / Rachana to check/
- Clinical waste is categorised and stored in line with our waste management policy and collected weekly.
- Domestic waste is disposed of via a contract with the local council. Collections take place weekly.
· Audits have been completed quarterly by Rachana Khatri
· Last audit completed by Rachana Khatri on the 4th of January 2019.
· On the 12th of September 2018 an audit took place using internal audit of waste management self-audit tool produced by the General Practitioners Committee (GPC) of the British Medical Association, with the support of the Environment Agency, which is designed to assist general medical practices in completing the pre-acceptance requirements for waste disposal. This audit has to take place every 5 years.
- Evidence is available for reference in the Infection Control Audit Folder.
Fixtures, Fittings & Furniture
- Seating audit completed in December 2018.
- Waiting area chairs / couches that needed repair have been repaired and replaced in January 2019. We have been replaced the chairs in all consulting rooms in March 2019.
- There were also some major repairs to the ceiling and walls done in the period: April 2018- April 2019 to create extra clinical space and waiting room areas in view of new requirement of 3 doctors and 2 nurses this past year.
· Patients who are thought to have an infection that may be contagious i.e. chickenpox are asked to wait in a designated isolation room rather than the main waiting room. The reception staff has been informed to isolate these patients.
· There have been no reported cases of MRSA acquired in the practice since last annual statement.
· Regarding minor surgeries done in the surgery there are no reports of infection, uterus perforation on bleeding as a consequences of the procedure.
i. Procedures carried out:
§ Coils and Nexplanon insertion and removal;
§ Joint injections;
§ Skin tags and minor lumps removal.
Policies, procedures and guidelines
All policies, procedures are in in Health & Safety Folder and Infection Prevention Control Folder.
Responsibility for ensuring its policies and protocols are followed: Dr Nalini Modha and the infection control, team and the every staff member.
Joanna, Robertas and Rachana are responsible for regular monitoring of the standard of cleaning throughout the practice and reporting to Monica Glapa Cleaning Manager if any problems are identified.
The Cleaning Manager is responsible for liaising directly with the cleaners alongside Clinical Manager Dr Nalini Modha who will be informed if any issues are identified which need further escalation.
Our Annual Statement of Infection Control is uploaded onto our practice website:
Updated: April 2019
Dr Nalini Modha (clinical manager).
Next Annual Statement due: April 2020.
Team Responsible: Dr Nalini Modha, Kanize Panjwani, Paul Watson, Joanna Kondek, Robertas Grabauskas, Rachana Khatri, Monika Klosowicz, Paulina Piatkowska, Monika Glapa