The Care Quality Commission
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Archived: Cottenham Surgery

Overall: Good read more about inspection ratings

Lewis House, 188 High Street, Cottenham, Cambridge, Cambridgeshire, CB24 8SE (01954) 250079

Provided and run by:
Dr Tanya Susan Blumenfeld

All Inspections

1 August 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at Cottenham Surgery on 1 August 2019.

We decided to undertake an inspection of this service following our annual review of the information available to us and to follow up on breaches of regulations identified at a previous inspection on 15 January 2018.

This inspection looked at the following key questions:

Are services safe?

Are services effective?

Are services well-led?

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 Good overall.

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

  • There were gaps in the provision of fire safety and the service had not assessed risks to the health and safety of service users and staff of providing the service and had not ensured the premises were safe for their intended purpose.
  • The provider recently had carried out an internal infection prevention and control audit which had identified a number of areas for improvement including a lack of up to date infection control policy, gaps in the provision and suitability of staff training and a lack of protected time for the lead infection control nurse to carry out their responsibilities. Whilst the provider was aware of these issues, they had not been resolved at the time of our inspection.

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

  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.

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

The area where the provider could improve and should:

  • Review the provision of health checks for patients to identify and proactively treat common serious health conditions.
  • Continue to provide staff with protected time for non-patient facing duties, development and training needs.
  • Develop a clear vision and set of values for the service.
  • Review how the service records and acts on verbal patient feedback and consider reinstating a patient participation group.
  • Consider how childhood immunisation and cervical screening uptake rates can be improved.

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

25 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a desk based review for Cottenham Surgery on 25 May 2016. This was to follow up on actions we asked the provider to take after our announced comprehensive inspection on 15 December 2015. During the inspection in December 2015, we identified that the provider had to make improvements to implement infection control audits and any required actions. The provider wrote to tell us about the actions they had implemented in order to comply with Regulation 12: safe care and treatment.

Our key findings were as follows:

  • The practice had a safe system in place to assess and monitor infection control practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cottenham surgery on 15 December 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, and addressed but learning and outcomes were not always shared.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, displaying the number of missed appointments and the impact this had.

We saw three areas of outstanding practice:

  • The practice had written a new policy for safeguarding children and this had been shared with a group of local practices. This has resulted in an improved shared approach to safeguarding children across the geographical area.

  • The practice had a proactive PPG which had been involved in a variety of activities with the practice, including decorating the practice and the inclusion of articles in local circulars.

  • The practice had a proactive commitment to facilitating care for the large traveller community based locally, engendering a high level of engagement. This was illustrated by a recent audit which showed that the practice had successfully supported travellers to access the service and, in particular, to receive immunisations.

The areas where the provider must make improvement are:

  • Infection control audits must be undertaken and any required improvements implemented.

The areas where the provider should make improvement are:

  • Implement a robust system to ensure that relevant staff see and implement necessary actions from patient safety alerts, including alerts and safety updates from the Medicines and Healthcare products Regulatory Agency (MHRA).

  • Risk assess the need for Disclosure and Barring Service checks to be undertaken for non-clinical staff.

  • Consider provision of opening hours that reflect the needs of working age people.

  • Implement a robust risk assessment system, including premises related risks.

  • Improve confidentiality at the front desk and for phone calls as conversations could be overheard in the waiting area.

  • Complete clinical audit cycles and record the findings.

  • Record minutes of meetings appropriately with any resulting actions allocated to named staff for action.

  • Share learning from complaints and significant events with all relevant staff and other necessary parties and document this appropriately.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice