The Care Quality Commission
  • Doctor
  • GP practice

Huntingdon Road Surgery

Overall: Good read more about inspection ratings

1 Huntingdon Road, Cambridge, Cambridgeshire, CB3 0DB (01223) 364127

Provided and run by:
Huntingdon Road Surgery

All Inspections

25 August 2023

During a routine inspection

We carried out an announced comprehensive at Huntingdon Road Surgery on 25 August 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - outstanding

Following our previous inspection on 01 October 2021, the practice was rated good overall and for all key questions but effective that was rated requires improvement.

At this inspection, we found that those areas previously regarded as requires improvement practice were now embedded throughout the majority of the GP practice. The practice had improved clinically and they had demonstrated areas previously regarded as good had improved and were embedded fully in the practice, therefore, caring, responsive and well led services were considered to be good.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

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 provided care in a way that kept patients safe and protected them from avoidable harm and 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.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers and the surrounding community to share and deliver best practices. There was a wide range of services, clinical and non-clinical that recognised that a patient’s emotional and social needs were as important as their physical needs.
  • 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.
  • Urgent and non-urgent patients, were referred appropriately and efficiently to the most suitable health care professional.
  • There was a clear leadership structure that promoted teaching, training, and development opportunities for staff and trainee GPs.

We saw several areas of wide ranging innovations the practice had introduced:

  • In response to patient feedback and identifying barriers to accessing support for children and young people’s mental health, the practice implemented a mental health community multi-disciplinary approach to care to provide holistic care. This involved the local community to ensure the highest quality care was delivered.
  • There was a strong emphasis on staff well-being and leaders would encourage the staff to engage in weekly mental health support walks.
  • There was a strong emphasis on developing health coaching innovations in response to recognising improvements in life expectancy and reducing hospital admissions. Patients felt in control and supported by the practice to manage their own health as much as possible.
  • The practice prided itself on continuity of care and there was a named doctor for the patients. In some cases, we saw the same GP had overseen the care of a patient for over 30 years. The leadership team had been invited to present this innovation within the Houses of Parliament.
  • Carers had an allocated staff contact at the practice to contact and were supported in a personalised manner.

We identified that the practice should:

  • Take action to engage in population group to improve understanding of the barriers to cervical screening.Encourage patients to register as carers in order to improve support and understand barriers for patients who have not registered as a carer at the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

01 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Huntingdon Road Surgery on 1 October 2021. Overall, the practice is rated as good.

Set out the ratings for each key question

Safe - Good

Effective – Requires improvement

Caring – Good (rating carried forward from previous inspection)

Responsive – Good (rating carried forward from previous inspection)

Well-led - Good

Following our previous inspection on 4 December 2019 the practice was rated requires improvement overall and for the key questions are services safe and effective. The practice had achieved a rating of good for providing caring, responsive and well led services.

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

Why we carried out this inspection

This inspection was a focused inspection of the safe, effective and well-led key questions to follow up on any breaches of regulations and areas the practice should improve that were identified at the previous inspection.

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 clinical staff interviews using video conferencing
  • Completing 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.

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 have rated this practice as good overall and good for all key questions, except the effective key question, which we have rated as requires improvement.

We found that:

  • Since the previous inspection the practice had strengthened their approach to risk management. For example: Evidence provided demonstrated that the practice had ensured portable appliance testing had been carried out by a qualified person to ensure electrical equipment was safe for use.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. This included enhanced infection control procedures.
  • Governance arrangements had been strengthened to ensure risks to patients were considered, managed and mitigated appropriately.
  • Effective procedures for the management of medicines had been strengthened to ensure patients received the appropriate reviews. This included the appropriate monitoring of patients on anticoagulant medicines.
  • There was emphasis on staff wellbeing, and this was demonstrated through discussions with staff and evidence of appraisals. Staff were encouraged to develop and were provided with training opportunities.
  • At the previous inspection we found the practice were unable to demonstrate how prescription stationery was monitored at the branch site. During this inspection we carried out a visit to the branch site and found processes had been strengthened to ensure prescription stationery was monitored and stored securely.
  • Risk management processes were in place and we found assessments of risks had been completed. These included fire safety, health and safety, and infection control. This ensured that risks had been considered to ensure the safety of staff and patients and to mitigate any future risks.
  • There was a strong focus on learning and development. The practice was a training practice for GPs, however they had expanded their educational facilities to provide training for student nurses and physician associates.
  • The practice was involved in a range of projects to improve the care of patients within the local community.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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

  • Continue to encourage patients to attend childhood immunisations and cervical screening appointments.

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

4 December 2019

During a routine inspection

This practice is rated as Requires Improvement overall. At the previous inspection in May 2016 the practice was rated as Outstanding overall.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

Are services at this location safe?

Are services at this location effective?

Are services at this location caring?

Are services at this location responsive?

Are services at this location 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.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

The practice was rated as requires improvement for providing safe services because:

  • We saw that portable appliance testing (PAT) was not carried out by a qualified person to ensure electrical equipment was safe to use. The provider told us that visual checks were completed by practice staff. However, no documentation was provided to demonstrate staff had the competency for this role. Following the inspection, the practice informed us PAT had been booked for January 2020.
  • We found that fire and health and safety risk assessments were generic and lacking in detail specific to the practice premises. This did not provide assurance that all potential risks had been identified by the provider.
  • The practice provided examples of infection prevention and control audits. However, these audits did not cover the entire practice premises and the most recent audits in several areas were last undertaken in 2016.
  • The practice did not provide evidence clinical staff had complete oversight of relevant blood test results prior to prescribing warfarin. Following the inspection, the practice told us a new system had been implemented to ensure warfarin was only prescribed following receipt of a relevant blood test result.
  • We found that the system for monitoring prescription stationery was not effective at the branch site.

The practice was rated as requires improvement for providing effective services because the population groups of people with long-term conditions and working age people were rated as requires improvement. These population groups were rated as requires improvement because:

  • We found the practice had a higher Quality Outcomes Framework exception reporting rate for all long-term condition indicators; some of which were significantly higher than the Clinical Commissioning Group (CCG) and England averages. The practice were aware of this data; however, there were no plans to reduce the number of exceptions made.
  • The practice’s cervical screening uptake was significantly lower than the 80% Public Health England target rate at 54.4%.

In addition to these findings, we found:

  • Not all staff had received an appraisal in the last 12 months. We found that three members of staff had not received an appraisal since June 2018 and ten appraisals scheduled for October 2019 had not taken place at the time of inspection. Following the inspection, the practice provided evidence that all staff appraisals had been completed.

The practice was rated as good for providing caring, responsive and well-led services.

We also found that:

  • The practice had clear safeguarding processes and procedures; staff we spoke with were knowledgeable about safeguarding and the practice’s systems.
  • The practice had implemented a clear system of roles and responsibilities within the practice. Staff we spoke with were clear on these roles and responsibilities and who to approach for individual issues.
  • Arrangements for dispensing medicines at the practice kept patients safe.
  • The practice’s uptake of childhood immunisations was above the 90% World Health Organisation target rate.
  • Patient satisfaction through the National GP Survey was positive and most indicators were above the CCG and England averages. This was further evidenced through CQC comment cards received during the inspection and through patient consultations on the day of the inspection.
  • Staff told us they felt well supported by the leadership team who were visible and approachable.

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.

The areas where the provider should make improvements are:

  • Review and improve systems for monitoring patients in the secondary waiting area.
  • Review and improve the system for prescribing warfarin.
  • Review and improve the practice’s cervical screening uptake rate.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

5 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Huntingdon Road Surgery on 5 April 2016. Overall the practice is rated as outstanding.

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

  • Patient feedback scores from the NHS GP Survey, the Friends and Family Test (FFT) and from our own comments cards was extremely positive about the practice. Patients expressed high satisfaction levels with the service citing attentive and caring staff, continuity of GP, the quality of treatment and speedy referrals as the reasons. 174 of 176 patients who completed the FFT would recommend the practice. 88% of respondents would recommend this surgery to someone new to the area.

  • GPs held individual patient lists, encouraging good continuity of care and enabling strong relations to be built up between them and their patients.

  • There was an open and transparent approach to safety and effective systems in place to report and record significant events which enabled learning to be shared.

  • Safeguarding was given a high priority, and the practice had comprehensive, robust and effective procedures in place to protect patients.

  • Risks to patients were assessed and well managed. There was a robust programme of infection prevention and control in place which was facilitated by the infection control lead GP.

  • The practice worked closely with other health and social care teams and local community organisations such as university college nurses and the Alzheimer’s Society to deliver co-ordinated and effective care for patients.

  • The practice used a wide range of both clinical and non-clinical audits to monitor and improve outcomes for patients.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had a high level of training for their roles and were well supported in their work.

  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

  • High standards were promoted and owned by practice staff with evidence of good team working across all roles.

We saw one area of outstanding practice:

  • The practice had a committed and very active safeguarding lead who worked hard to ensure patients were protected. For example, in January 2016 and in addition to regular meetings with the health visitor, she had checked and updated the practice’s paediatric and domestic violence folder;hadcreated a document in relation to Gillick and Fraser guidelines and completed all pending items on the practice’s section 11 safeguarding audit. The practice’s child safeguarding learning reports had been used as a model example by other local safeguarding agencies.

The areas where the provider should make improvement are:

  • Implement a protocol for the non-collection of prescriptions and medicines by patients.

  • Read code children who do not attend hospital appointments on the practice’s clinical IT system and develop an appropriate follow up contact protocol.

  • Actively flag informal carers on the practice’s clinical IT system to make them easily known to staff.

  • Undertake regular fire evacuation simulations at the Girton branch.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice