Archived: Cottenham Surgery

Updated 27 September 2019

Cottenham surgery is located at Lewis House, 188 High Street, Cottenham, Cambridge, Cambridgeshire, CB24 8SE.

The provider is registered with the care quality commission (CQC) to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.

Cottenham Surgery is situated within the Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) and provides services to 3,856 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.

The practice is run by a sole GP and has one part time salaried GP, one practice nurse and one health care assistant. The clinical team is supported by an interim part time practice manager and a team of six administrative, secretarial and reception staff.

The practice is a teaching practice and supports medical students as part of their eight-week placement in general practice. It does not act as a training practice for GP registrars.

Public Health England information shows the patient population has a higher than average number of patients aged 0-14, 35-44 and 85+ compared to the practice average across England. It also has lower proportions of patients aged 15-29 and 55-59 compared to the practice average across England. Income deprivation affecting children and older people is lower than the practice average across England and the overall deprivation across its population is considerably lower than the national average.

Updated 27 September 2019

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

Updated 27 September 2019

Updated 27 September 2019

Updated 27 September 2019

Updated 27 September 2019

Updated 27 September 2019

Updated 27 September 2019