Waterbeach Surgery

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence the service understood the needs of the people and communities it served and put them at the centre of how care was planned and delivered. We looked for evidence people accessed the care and treatment they needed.

At our last assessment with the previous provider, we rated this key question requires improvement. At this assessment we have rated this key question good.

People were involved in decisions about their care and treatment. The practice provided information in a way that people could understand. People knew how to share feedback and were confident their views would be listened to and acted upon. Staff supported people fairly and without discrimination, while training and feedback helped address health and care inequalities. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice placed patients at the heart of their care and treatment. Staff took the time to understand what mattered most to people and worked alongside them to ensure care reflected their changing needs, wishes and goals. Patients, the PPG and care home representatives spoke positively about the personalised approach staff applied to care and support provided by the practice.

The practice recognised the specific healthcare needs of veterans and held veteran friendly accreditation. Staff were aware of dedicated support pathways and examples included timely referrals to services designed specifically for veterans.

Staff described a collaborative approach to consultations, ensuring patients were listened to, informed and involved in planning their care. Evidence from clinical records demonstrated that patients were supported to understand their health conditions and participate fully in decisions about treatment and ongoing care.

The practice had a good understanding of the diverse health and care needs of its patient population and local community. This enabled a proactive and flexible approach to service delivery, which ensured that care was coordinated and personalised to individual needs. The practice worked collaboratively with a range of partner organisations, including community groups, healthcare providers and local care homes, to support health and wellbeing. Through these partnerships, practice staff tailored their approach to meet the specific needs of the practices’ population and strengthen community engagement.

A stable clinical workforce and established multidisciplinary relationships supported continuity of care for patients. People who provided feedback told us that they felt staff understood their needs and responded effectively to their individual circumstances.

Information about a range of support services, including wellbeing and mental health resources, was available both within the practice and on the practice website. Information to promote the take up of screening and immunisation programmes was available. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. The practice made sure that people were informed about to how to access their care records. People we spoke with did not raise any concerns in this area. Leaders actively encouraged patients to provide feedback and had established a variety of methods for people to share their experiences and views about the service.

The practice actively sought feedback from patients and made it easy for people to raise concerns, share ideas and contribute to service improvements. Staff ensured patients were involved in decisions about their care and kept informed of changes made in response to feedback. Leaders ensured there were multiple ways for patients to provide comments about their care and treatment.

The percentage of respondents to the GP patient survey at the time of our assessment who stated that during their last appointment they were involved as much as they wanted to be in decisions about their care and treatment was 91%. This is in line with expected national and local averages.

Clear information about the complaints process was available both in the practice and online. Our review of complaints showed they were handled openly and transparently, with timely investigations, appropriate apologies and actions taken to address concerns. Patients were also given information about independent escalation routes, including the Parliamentary and Health Service Ombudsman.

Patient feedback was valued and used to drive continuous improvement. Staff were able to describe examples where learning from complaints had led to positive changes in practice processes and patient experience.

The practice recognised that results from the National GP Patient Survey (2025) relating to access were below the expected average. For example, 43% of respondents said that it was easy to contact the practice on the phone, this was 10% below the expected average. In response to this feedback, practice staff monitored access and demand through patient feedback and operational data. Since the inspection, the National GP Patient Survey have published new results, in July 2026. The new data suggests a slight improvement with 45% of respondents reporting that it was easy to contact the practice by telephone. Despite this improvement, performance remains below the local and national average.

Practice staff made sure that people could access the care, support and treatment they needed when they needed it. People could access the service to suit their needs for example online, in person and by telephone. The practice also worked closely with the Primary Care Network (PCN) to offer appointments at other surgeries or see patients from other surgeries within the PCN when appropriate.

Physical access at the Cottenham site presented a number of challenges, with multiple steps located throughout the premises. Adaptations had been made to support people who use a wheelchair and individuals with reduced mobility, including the installation of handrails and the use of temporary ramps to enable access to the waiting area and clinical rooms. Arrangements were in place to ensure patients with mobility needs could be seen in ground floor consultation rooms.

The second floor was accessible only via a steep staircase, as the stair-lift previously installed had been removed due to safety concerns. Access to most rooms on this level involved steps and there were additional challenges of uneven floors. Regular safety inspections of the premises were undertaken. Following these assessments, a recommendation was made for the practice to relocate to alternative premises. The practice was in the process of progressing this recommendation and plans were being developed for a new site.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations.

The practice worked closely with a range of local care homes. There was a strong focus within the practice to reduce the number of hospital admissions for the residents. Practice staff undertook additional work to investigate themes and trends relating to hospital admissions and as a result tailor their approach to care. Practice staff and leaders told us that they had found that there had been a reduction in hospital admissions since undertaking this work and building close working relationships with the local care homes, patients and their families.

The practice had also chosen to be accredited as a Veteran Friendly GP Practice. Practice staff identified and supported people who serve or have served in the armed forces and their families. The practice took the specific needs of veterans into account in planning changes and improvements, for example with referrals to specific health services.

Feedback provided by people using the service was positive. Staff treated people equally and without discrimination. Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. There were processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

Some of the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions we looked at during our assessment had not been recorded in line with relevant legislation. When a decision about DNACPR had been made, a code was usually added to the patient’s record to alert staff. Clinicians in the practice relied on these codes to identify patients for whom a decision about DNACPR had been made. However, not all the records we reviewed were clear and staff were sometimes unable to find information on the clinical records system explaining the patient’s wishes and how the decision had been made. This meant there was not always evidence these decisions had been made in line with legislation, or involved patients, and their relatives and carers.

Following our site visit the practice reviewed their processes with managing and recording DNACPR decisions. Leaders provided assurances that a streamlined process would be implemented and embedded into the practice. They also confirmed that an audit would be carried out to ensure that all previous DNACPR decisions would be legible and easy to access.