Archived: Waterbeach Surgery

Updated 20 January 2022

Waterbeach Surgery provides services to a population of approximately 5,670 patients.

The practice is contracted to provide Alternative Provider Medical services (APMS) by Cambridgeshire and Peterborough Clinical Commissioning Group.

The provider, MKGP Plus Limited had been the registered provided since December 2020. MKGP Plus Ltd is a healthcare provider organisation that is a subsidiary of the MKGP Ltd. MKGP Plus Limited has an overarching board and includes a chair, deputy chair, chief and a deputy operating officer. There is a finance director, medical director and Director of Operations. Other members of the senior management team include a clinical lead, and operations managers.

At Waterbeach Surgery, there is a GP clinical lead (male) and two salaried GPs (one male and one female). There are two practice nurses and two health care assistants. There is a practice manager and an office manager who are supported by a team of reception and administrative staff who undertake various duties. The practice is further supported by other members of the wider MKGP Plus Limited clinical team who work remotely.

The practice works with a local primary care network and has access to other staff such as a social prescriber and pharmacist.

The practice provides a range of clinics and services, detailed in this report, and open between the hours of 8:30am and 6pm weekdays.

The practice also offers extended access appointments on evenings and weekends through a Federation of local practices. In addition to this, outside of practice opening hours, a service was provided by another health care provider, Herts Urgent Care, via the NHS 111 service.

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.

Updated 20 January 2022

We carried out an announced inspection of Waterbeach Surgery on 9 December 2021. Overall, the practice is rated as requires Improvement .

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive – Requires improvement

Well-led - Requires improvement

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the second inspection of Waterbeach Surgery under the registered provider MKGP Plus Limited. MKGP Plus Limited became the provider of Waterbeach Surgery from December 2020.

We had previously inspected the practice under the current provider, in June 2021 and the practice was rated as requires improvement overall.

We had previously inspected the Waterbeach Surgery under the previous provider and published our report dated 7 December 2020. At this inspection we rated the practice inadequate overall, imposed urgent conditions and the practice remained in special measures. Under our continuing regulatory history policy, the location inherited the rating of inadequate and remained in special measures but the conditions which had been imposed on the previous provider were not inherited.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on concerns we had received, the breach of regulation and areas where the provider ‘should’ improve identified in our 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 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
• Staff questionnaires

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 Requires Improvement overall

We found that:

• The practice provided care in a way that generally kept patients safe and protected them from avoidable harm.
• We found an inconsistency in the reviewing and coding of medicine reviews. There were a significant number of medicines reviews that had not been fully documented or not undertaken in the past 12 months.
• We found some gaps in the monitoring and clinical oversight of all clinical staff performance and medical record keeping.
• We found examples of poor coding in respect of patients with chronic kidney disease.
• 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 adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Although GP patient survey data was still below CCG and national averages, the practice had made significant improvements and patients’ feedback about their experience of accessing the practice had improved.
• The practice had recruited additional staff and had an active recruitment plan to employ further clinical staff.
• Feedback from staff was positive about practice level management but we received negative feedback from staff about the wider organisation leadership and support to the practice. Changes within the wider organisation management team had resulted in less clinical management and oversight at local level.

We found breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care

In addition, the provider should:

• Continue to monitor and improve patient experience relating to access to the surgery.
• Continue to monitor and improve uptake for cervical screening programme.

I am taking this service out of special measures. This recognises the improvements that have been 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 tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care