The Care Quality Commission
  • Doctor
  • GP practice

Boleyn Medical Centre

Overall: Good read more about inspection ratings

152 Barking Road, East Ham, London, E6 3BD

Provided and run by:
Dr Mohammad Samin Jan Khan

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Boleyn Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Boleyn Medical Centre, you can give feedback on this service.

Off site inspection

During an inspection looking at part of the service

We carried out an announced review of Boleyn Medical Centre on 19 May 2022. Overall, the practice is rated as good.

Responsive - Good

Following our previous inspection on 26 October 2020, the practice was rated good overall and for all key questions, except responsive that was rated as requires improvement.

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

Why we carried out this review


This review was a focused review without undertaking a site visit inspection to follow up on:

  • The practice system to manage significant events.
  • Below average GP Patient Survey data for patients’ satisfaction with caring and responsive services.
  • Systems to improve below target or below average clinical performance data for; cancer, chronic obstructive pulmonary disease (COPD), and uptake rates for childhood immunisations.

How we carried out the review


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 reviews differently.

This review was carried out off site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Requesting evidence from the provider.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• 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 Good overall

We found that:

• There were appropriate systems to identify and manage significant events.
• The practice took effective action to improve patient’s experiences of caring and responsive services that were reflected in improved GP Patient Survey data.
• The practice adjusted how it delivered services to meet the needs of patients during the Covid-19 pandemic, including to maintain and improve clinical performance data for; cancer, chronic obstructive pulmonary disease (COPD), and uptake rates for childhood immunisations.

Whilst we found no breaches of regulations, the provider should:

• Continue to monitor and improve clinical performance data such as for; cancer and uptake rates for childhood immunisations.

Details of our findings and 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

26 October 2020

During a routine inspection

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.

At this inspection, we have rated the practice as good overall.

We rated the practice as good for providing safe services because:

  • Staff had completed adult and child safeguarding training to an appropriate level for their role.
  • Recruitment checks were carried out in accordance with regulations and a record of staff vaccination was maintained.
  • Medicines management arrangements had improved, including for high risk medicines patients monitoring and prescribing, prescriptions usage monitoring, and to ensure appropriate emergency medicines were held.
  • Appropriate safety checks and procedures had been put in place in relation to the premises, such as fire safety.
  • Following our previous inspection, the practice had put in place a new system to manage and follow up safety alerts and significant events.

We rated the practice as good for providing effective services because:

  • Patients’ needs assessment and care and treatment was delivered in line with current legislation, standards and evidence-based guidance, although some clinical performance data was below average such as cancer, COPD and childhood immunisations.
  • The practice reviewed and monitored the effectiveness and appropriateness of the care and treatment it provided through a comprehensive quality improvement program.
  • The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • The practice obtained consent to care and treatment in line with legislation and guidance.
  • These areas affected all population groups, so we rated all population groups as good for providing effective services.

We rated the practice as good for providing caring services because:

  • The practice had discussed the GP Patient Survey results for 2020 and had put in place a documented action plan to improve patients’ experience. Although further work was needed to see some changes through, due to an appropriate focus on clinical risk.
  • Feedback we received from members of the Patient Participation Group (PPG) advised that the practice meets the needs of and listens to its patients.
  • The practice had improved arrangements for patient support and privacy such as for bereaved and carers support and information.

We rated the practice as requires improvement for providing responsive services because:

  • The practice had remedied most concerns identified at our previous inspection, but there was insufficient evidence of effective action to improve patients lower than average satisfaction expressed through the GP Patient Survey, particularly patients access to the service.
  • The practice had taken immediate action and subsequent action in response to COVID 19 to ensure access arrangements were effective and appropriate.
  • The practice had two additional telephone lines and an online triage system with a response to patients within 48hours.
  • The practice had improved its arrangements for receiving and acting on complaints that were listened and responded to and used to improve the quality of care.

These areas affected all population groups, so we rated all population groups as requires improvement for providing responsive services.

We rated the practice as good for providing well-led services because:

  • Following the last inspection there had been improvements to continuity plans in the event of the absence of the lead GP.
  • Following the previous inspection in July 2019, the practice had created a specific action plan which detailed the risks that had been identified; this plan was monitored and updated to ensure that risks were addressed and escalated where necessary.
  • We saw that clinical oversight and systems to ensure good governance had improved.
  • All of the specific concerns we identified at the previous inspection had been satisfactorily addressed at this inspection, in line with risk.
  • Staff told us they were able to raise concerns and that management and leaders were approachable.

The areas where the provider should make improvements are:

  • Continue to act to improve and evaluate patients’ satisfaction with caring and responsive services, particularly access.
  • Continue to monitor and improve some areas of clinical performance such as cancer COPD, and uptake rates for childhood immunisations.
  • Review and improve systems for significant events to ensure relevant considerations are documented and managed consistently.

I am taking this service out of special measures. This recognises the significant improvements 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 table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

22 July 2019 and 25 July 2019

During a routine inspection

We decided to undertake an inspection of this service on 22 and 25 July 2019 following our annual review of the information available to us. This inspection looked at the following key questions; are services safe, effective, caring, responsive and well-led.

The practice was previously inspected in October 2016 and was rated as good overall.

Our judgement of the quality of care at this service is based 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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have effective arrangements to keep children safeguarded from abuse.
  • The practice did not have clear systems and processes to keep patients safe, including the management of safety alerts and significant events, and to ensure early recognition of sepsis.
  • There were gaps in systems to assess, monitor and manage risks to patient safety including infection control and fire safety.
  • The practice did not have appropriate systems in place for the safe management of medicines including high risk medicines.
  • The practice did not learn and make improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

  • There was no monitoring of the outcomes of care and treatment.
  • Appropriate arrangements for care and treatment such as patients call and recall, and care planning were not effective.
  • Some clinical performance data was below local and national averages and there was no clear or effective action plan to improve.
  • The percentage of new cancer cases treated detection rate which resulted from a two week wait (urgent) referral was 20%, which was below both local and national averages.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as requires improvement for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Arrangements to ensure patients privacy in the reception area needed improvement.
  • Systems to identify carers required review and improvement.

We rated the practice as inadequate for providing responsive services because:

  • People were not able to access care and treatment in a sufficiently timely way.
  • The registered person had failed to establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users.
  • Individual complaints were addressed for individual patients, but complaints were not used for learning or to improve the overall quality of care.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as inadequate for providing well-led services because:

  • The practice did not have a forward vision or strategy.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.
  • We were not assured leaders had the capacity and skills to deliver high quality, sustainable care.
  • The provider had not applied to register relevant regulated activities as required with the CQC as required.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure patients are protected from abuse and improper treatment.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • Ensure there is an effective system for identifying , receiving ,recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure specified information is available regarding each person employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review and improve arrangements in the patient’s reception area to ensure patients privacy is maintained.
  • Review and improve arrangements to promote patient’s access to relevant health screening and health promotion information.
  • Review and improve contents of patients care plans for patients with a learning disability, and to support patient self-management.
  • Review and improve systems to identify carers.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and 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

17 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boleyn Medical Centre on 17 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Improve processes to identify patients who are also carers to ensure that their needs are identified and met.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice