Statement of purpose and infection control

Statement of purpose (as of February 2022)

The name and address of the registered provider is:

Thistlemoor Medical Centre

6-10 Thistlemoor Road

New England


Registered Manager: Dr. Neil Modha

Practice Manager: Ms. Paulina Janczura

Legal Status: Partnership

Service Types: Doctors Consultation Service

Doctors Treatment Service

Regulated Activities:

Treatment of disease, disorder or injury

Surgical Procedures

Diagnostic and Screening Procedures

Maternity and Midwifery

Family Planning Service

Vaccination services

Service Users:

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.

Due to Coronavirus we have developed an external site for flu and coronavirus vaccination delivery. This involves 3 vaccine cabins towards the rear of the Practice near the Staff Car Park.

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

Health Care.

The Primary Health Care Team

The Partners:

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,


Medical Team

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

Dr Sundeap Odedra

Dr Sidra Malkera

Dr Abdullah Hussaini

Dr Oyidiya Ukpabi

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)

Joanna Kwiatecka

Kamil Klosowicz

Rosie Mahmood

Rebecca Perry

Nadia Batul

Theresa Samel

Kanize Panjwani

Emilia Wiercbicz

Practice Pharmacists

Katarzyna Lukaszewska

Timothy Kujiyat

Atiya Ajaib

Dassine Hamici

Shilpa Patel

Masuma Damani


Jose Cordero

Health Care Assistants

Healthcare assistants have appointment sessions for venepuncture, blood pressure and pulse measurements, as well as ECGs and healthy living screening. 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.


Practice Manager

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.

Practice Staff

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.


Home Visits

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.

Booking Appointments

The practice runs open-access surgeries where by any patient registered at the Practice can be contacted by the Practice team Monday to Friday 8:30am to 12pm. 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 telephone lines. We encourage patients where possible to use engage consult our on-line consultation tool that helps our patients to let us know they want our support by sending an electronic message to us and providing details of how they would like support. 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 run in a similar way with telephone contact first. If the clinician determines they need to see a patient this will be done by video consultation or the patient will be brought to the practice. Patients will be asked questions relating to Covid symptoms, whether they are isolating and will be asking where possible to where a mask if they are invited to the practice. The clinicians often have review slots booked in before and after morning surgeries this allows patients to be booked in for reviews.


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 and smear tests.

Maternity Services

Midwife clinics are held daily for our patients. The local hospital maternity department provides this service with community midwives.

Cervical Screening

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 normally provide an implant service or the insertion of coils and implants, this is currently suspended during the coronavirus pandemic.

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.

Joint Injections

Therapeutic joint injections are carried out by Dr Neil Modha, Dr Karen Hamilton and Dr Azhar Chaudhry.

Minor Surgery

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.

General Information

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.


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: January 2022

Review Date February 2023

Signed by Registered Manager_____Dr Neil Modha________

Annual Statement of Infection Control updated February 2022


An annual statement is generated each year in April 2021. The next annual Statement is due in April 2022.

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. The infection Control Nurses lead is Nadia Batul and Nurse Lead Ajmal Raza can be contacted for general queries for nurses.

The Administrative leads are Joanna Kondek, Roszia Bi, Rachana Khatri, Paulina Piatkowska and Monika Klosowicz.

Significant events

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.

All significant events documentation is reviewed and discussed in clinical meetings and Practice Meetings with all staff regularly.


The main team responsible for completing the audits is Monika Klosowicz and Paulina Piatkowska supported by Roszia Bi and Rachana Khatri.

The purpose of the audits is to establish whether all clinicians are 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 effectively placed on the walls.

The audits are repeated at three monthly intervals to ensure good practices are maintained 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 in the morning and cleaned 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 September 2021 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:

1. Action Plan: the cleaner’s supervisor - Rachana was to complete and supervise the general audit as per job specification in the general cleaning process of those areas.

2. The last cleaning meeting with all cleaners and leads took place on 21st April 2021. For reference please see Appendix III – Minutes of the meeting.

3. Attendees at the meeting were: Rachana K, Piotr L, Joanna Kondek, Illeana, Gina, Kasia and Magda.

4. Topics discussed were as follows:

General overview of the cleaning areas with the responsible cleaners affected to each one (Appendix IV);

Working patterns

Cleaning duties when covering for colleagues

Cleaning equipment use

Curtain Cleaning SOP discussed

Discussed waste protocol

Hand Washing Techniques Assessment and Panic Alarm completed training on 09.12.2021.

5. Hand washing training took place on 09th December 2021 for new staff and the update for the current staff.

6. In all room and utilities areas Hand wash Hygiene Technique data sheet were checked and replaced when necessary due to poor state of repair.

7. A hand sanitizer was supplied to clinicians for their visiting bags for home visit.

Infection Control and Health & Safety Training was provided by Dr Neil Modha on 13th September 2021.

- The following topics discussed at this meeting:


Infection Risk Roles and Responsibilities

Chain of Infection

Sharp Disposal

Single Use Symbol

Spillage Protocol

Legionella Risk Assessment was done on 25th November 2021 and its next inspection is due to be in September 2022; For evidence and reference the physical folder is ought to be consulted with Piotr Lempicki. All recommendations are in place and working fully. (Awaiting report)

9. Action Plan: a meeting with Piotr Lempicki to check the full documentation was in place. Legionella Policy has been reviewed in September 2021. The next review is planned in September 2022.

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.

1. Action Plan: The last training was provided Dr Neil Modha in September 2021. Discussing chain of infection, cold chain and handling of vaccinations.

2. A meeting with cleaners took place on the 21.04.2021 to ensure that all cleaners are aware of the waste protocol. They were reminded about use of recycle bins and changes accordingly.

General Points:

Black Bin bags when discarded in the big skip needs to be slit to take excess air out from the bags and if anyone is being found guilty of not doing as requested would be disciplined

Yellow or Orange clinical waste bin liners needs to be tied before throwing them in clinical waste bins in the shed as SRCL has complained that some bags were open

We discussed waste management with a cleaning staff on the following meetings as well: 19.07.2021.

Last General Cleaners Meeting took place on the 21st of April 2021 with the presence of the all cleaners and cleaning Admin staff: Joanna K, Rachana K, Piotr L, Magda, Gina and Kasia and Ileana. This was a general meeting to inform the cleaning team to continue with the risk of Covid and the expectation from them and to answer any of their queries. We have informed the cleaner’s that in case of emergency when we get any patient who could be suspected case of Covid we would call them to come in and deep clean the consulting rooms and would provide them PPE for single use.

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 Roszia Bi in June 2021 and the next one is planned in July 2022. The responsible person to complete the next risk assessment is Roszia Bi.

Staff training

Staff are up to date with their infection control training delivered by Dr Neil Modha in three meetings:

Infection Risk Roles and Responsibilities

Chain of Infection

Sharp Disposal

Single Use Symbol

Spillage Protocol

The previous discussion of Infection Control meeting was on the 26th July 2021 below is what was discussed in the meeting:



Clinic Room Expectations

Cytoxic and Cytostatic medications- safe handling and administration

The previous discussion of Infection Control Meeting was on the 11th December 2021 below is what was discussed in the meeting:

Sharp Bins

Common Risks

COVID Protocols and Procedures

COVID 19 TRIAGE Pathways Flowchart for PPE guidance

PPE Standard Health and Social Care settings

Isolation Room Protocol

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 assembly 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.

The last Infection Control Training held on 13th September 2021 which included spillage protocols and chain of infection, infection risks and responsibilities. This has also been added as staff training.

PPE (Personal Protective Equipment)

The practice provides PPE for all members of the team in line with their role.

PPE audits completed by Monika K and Paulina P in October 2020 were done throughout and quarterly during the period of April 2020 to March 2021 and this is continued in 2021-2022 by Paulina P & Monika K

1. Evidence is available for reference in the Infection Control Audit Folder.

We discussed PPE with our cleaner’s staff on the meeting held on 21.04.2021 and the staff on the practice meeting on 11.12.2020.


Clinical waste is categorised and stored in line with our waste management policy and collected fortnightly

Domestic waste is disposed of via a contract with the local council. Collections take place monthly.

Confidential Waste stored in a locked console is collected once monthly via contract.

Clinical Waste is collected every fortnightly by SRCL.

Cardboard & Non Confidential Paper waste are being shredded by another company once a month.

Audits have been completed quarterly by Rachana Khatri, Nadia Batul, Rosie Mahmood

Last audit completed by Nadia Batul, Rosie Mahmood in January 2021

Evidence is available for reference in the Infection Control Audit Folder.

Fixtures, Fittings & Furniture

Seating audit completed in August 2021.

Waiting area chairs / couches that needed repair have been repaired and replaced in July 2021 Currently there are no chairs for replacing.

Patients Chair have been replaced in Zone A and B in August 2021 with wipeable chairs and other chairs have been repaired for wear and tear.

There were also some major repairs to the ceiling and walls done in the period: 2021 to date.


Patients who are thought to have an infection that may be contagious i.e. Covid or other infectious diseases like 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.

Staff follow the procedures for Covid which were specially created during the pandemic and are found in the infection control folder.

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.

1. Procedures carried out:

Coils and Nexplanon insertion and removal.

Policies, procedures and guidelines

All policies, procedures are in Health & Safety Folder and Infection Prevention Control Folder.

Responsibility for ensuring its policies and protocols is followed: Dr Nalini Modha and the infection control team and every staff member.

Joanna, Piotr and Rachana are responsible for regular monitoring of the standard of cleaning throughout the practice and reporting to the cleaners if any problems are identified.

Joanna, Piotr, Rachana are 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:

Annual Statement of Purpose and Infection Control 2021-2022

Annual Statement April 2021 Updated: in view of CQC inspection

Dr Nalini Modha (clinical manager).

Next Annual Statement due: April 2022

Team Responsible: Dr Nalini Modha,Nadia Batul, Joanna Kondek, Rachana Khatri, Roszia Bi, Monika Klosowicz, Paulina Piatkowska.