The Care Quality Commission
  • Doctor
  • GP practice

The Cambridge Practice

Overall: Good read more about inspection ratings

Aldershot Centre for Health, Hospital Hill, Aldershot, Hampshire, GU11 1AY (01252) 344868

Provided and run by:
The Cambridge Practice

Important: This service was previously registered at a different address - 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 The Cambridge Practice 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 The Cambridge Practice, you can give feedback on this service.

8 September 2021

During an inspection looking at part of the service

We carried out an announced inspection at The Cambridge Practice in Aldershot, Hampshire on 8 September 2021.

Following our previous inspection in July 2019, the practice was rated Requires Improvement overall with two key questions (the provision of safe and well-led services) rated as Requires Improvement. The remaining key questions (the provision of effective, caring and responsive services) were rated as Good.

At this inspection (September 2021), we found improvements had been made and the provider is now compliant with the regulations. We have re-rated this practice as Good overall and Good for all population groups, specifically we have rated the practice as:

  • Safe - Good
  • Effective – Good
  • Well-led - Good

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

Why we carried out this inspection

Given reported breaches of regulation from the July 2019 inspection, we issued a requirement notice for Regulation 17 ‘Good governance’ and for Regulation 19 ‘Fit and proper person employed’.

We carried out an announced inspection on 8 September 2021 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection in July 2019.

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 staff interviews using video conferencing
  • Completing remote 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 short site visit to the main site (Aldershot Centre for Health)
  • Discussions with practice staff and two patients

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 found that:

  • The practice had made significant improvements since our previous inspection in July 2019.

  • Systems had been strengthened to ensure safeguarding registers were monitored effectively. Regular reviews of the registers were carried out to ensure all the relevant information had been recorded appropriately and safeguarding arrangements protected patients from avoidable harm.

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm, including associated risks to the COVID-19 pandemic.

  • The practice was able to demonstrate staff had the skills, knowledge and experience to carry out their roles. Staff members were appraised annually and received appropriate supervision and training.

  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

  • Continuous monitoring of practice procedures, clinical outcomes and clinical registers was in place to ensure improvements were maintained. However, further improvement was required for some long-term conditions and cervical screening uptake.

  • The practice had various channels of communication and engagement with people who used the service. However, feedback from the patient participation group highlighted the practice hadn’t taken some of the groups feedback onboard.

  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care. The practice now had an effective governance system in place, was well organised and actively sought to learn from previous inspections, performance data, complaints, incidents and feedback.

We saw several areas of outstanding practice including:

  • The practice supported patients to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health. This included, designated workstreams and staff members to manage and coordinate health promotion for older people, people experiencing poor mental health, younger people and those with long-term conditions. This included the introduction of a framework referred to as a House of Care for a coordinated service model which enabled patients with long-term conditions to work together with clinicians to determine and shape the support needed to enable patients to live well with their condition. We also saw the practice had worked with other practices within the Primary Care Network, Clinical Commissioning Group and Integrated Care System to review health promotion post COVID-19. This included changes in patient behaviour as a result of the pandemic and lockdown restrictions.

  • The practice had continued to demonstrate a culture of community wellbeing to ensure equality for patients when accessing health care. For example, additional engagement with the local care homes, the Nepalese community, people with a learning disability, military veterans and other identified cohorts of vulnerable patients throughout the pandemic.

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

  • Continue to monitor and review diabetes related clinical outcomes and hypertension related clinical outcomes.

  • Continue to monitor and increase and cervical screening uptake.

  • Further improve patient engagement and communication processes through re-engagement with the patient participation group.

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

31 July 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Cambridge Practice on 31 July 2019 as part of our inspection programme.

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 requires improvement overall. In particular, we rated the practice as requires improvement for safe and well led services and good for effective, caring and responsive services. The population groups were also rated as good.

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

  • There were systems in place to keep patients safe, but some areas required a review. For example, staff training to the appropriate level for safeguarding, disclosure and barring service checks for clinical staff and ensuring staff recruitment checks were carried out in line with guidance. In addition, high risk actions arising from risk assessments required embedding.

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

  • There were some processes and systems that were not yet implemented or embedded, and some governance arrangements were in the process of being reviewed. For example, risk assessments with high risk actions requiring completion, staff appraisals to review performance, monitoring of consent seeking processes and complaints record keeping.
  • There had been a change in practice management since the formation of the new provider, which had resulted in some systems and processes being reviewed and actioned in a different way to those that were previously operated. The provider was aware of the areas requiring review and had an action plan to ensure these were managed in a timely way.

We rated the practice as good for providing effective, caring and responsive services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Review the intercollegiate guidance for child safeguarding and consider which level of training is required for non-clinical staff.

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