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Inspection Summary

Overall summary & rating


Updated 12 November 2019

We carried out an announced comprehensive inspection at Dr Wayne Cottrell on 25 September 2019. CQC previously inspected the service on 2 August 2018 and asked the provider to make improvements namely:

  • Review the level of oversight of and access to health and safety risk assessments for the premises.
  • Review the process for documenting fire evacuation drills.
  • Review the process for documenting the cleaning of medical equipment, such as the ear irrigator.
  • Review training requirements and updates for clinicians in relation to consent and the Mental Capacity Act 2005.
  • Review the necessity for interpretation services for patients whose first language is not English.

We checked these areas as part of this comprehensive inspection and found these issues had been addressed.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Dr Wayne Cottrell some services are provided to patients under arrangements made by their employer or an insurance provider with whom the patient holds an insurance policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, at Dr Wayne Cottrell, we were only able to inspect the services which are not arranged for patients by their employers or an insurance provider with whom the patient holds a policy (other than a standard health insurance policy).

The Provider is subject to a condition of registration to have a registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider did not have a registered manager at the time of the inspection. The provider had notified the Care Quality Commission of the absence of the registered manager. The Care Quality Commission had received an application from an individual to become the registered manager at the provider and was processing this.

We also asked for CQC comment cards to be completed by patients prior to our inspection. We received 68 comment cards. All the comments were positive. The comments emphasised the convenience of the service. It was easy to get appointments; the on-line booking system was easy to use. Patients spent little time waiting to be seen. The staff were good listeners, were caring and professional.

Our key findings were:

  • The care provided was safe. There were systems for reporting, investigating and learning from incidents. The provider was trained to the correct level in safeguarding and had made safeguarding referrals when appropriate.
  • Patients received effective care and treatment that met their needs.
  • There was an efficient and effective service for patients’ tests with almost all tests completed on the same day.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • There was effective leadership and staff expressed satisfaction about the work. There was a low staff turnover.

We saw the following outstanding practice:

  • All patients could specify how and when they wanted the practice to communicate with them. The practice systems were set up to accommodate this. This service was of particular importance to those attending the practice for sexual health appointments.
  • The practice offered anal Papanicolaou smear testing particularly for men who have sex with men. This test is an effective screening tool for anal cancer. The service is not generally available at other GP practices.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 12 November 2019

  • The service had processes and services to minimise risks to patient safety.
  • We found there was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice.
  • Risk assessments relating to the health, safety and welfare of patients using the service had been completed in full.
  • The provider demonstrated that they understood their safeguarding responsibilities.
  • The practice had adequate arrangements to respond to emergencies and major incidents.
  • Comments from patients confirmed that the service was safe in its approach and undertook rigorous health assessments prior to treatment.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems to assure that an adult accompanying a child had parental authority.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The provider was sensitive to different circumstances in which safeguarding issues might be found. For example, the provider had observed behaviour in a relationship which had caused them to report a possible instance of human trafficking to the appropriate authorities.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. For example, the doctors and nurses were trained to level three. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. The risks of Legionella had been assessed and there were appropriate mitigating controls.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. In our inspection of August 2018 we asked the provider to review the level of oversight of and access to health and safety risk assessments for the premises and to review the process for documenting fire evacuation drills. At this inspection we saw that the provider had addressed those concerns.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for new staff tailored to their role. The provider did not use agency staff.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.
  • There were appropriate professional indemnity arrangements and the provider checked these regularly.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing. The provider carried an antibiotic prescribing audit every three months to check that their prescribing was in line with latest guidance.
  • The service did not prescribe controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence).
  • Staff prescribed medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. There were processes were for checking medicines and staff kept accurate records of medicines.
  • There were effective protocols for verifying the identity of patients including children.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and acted to improve safety in the service. For example, a significant event had involved the disclosure of confidential patient information. The provider had made changes to the how this type of information was sent out so that the same incident could not happen again.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. There were systems for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism to disseminate alerts to all members of the team including sessional staff.



Updated 12 November 2019

The service provided evidence-based care which was focussed on the needs of the patients.

  • Patients received a comprehensive assessment of their health needs which included their medical history.
  • The service encouraged and supported patients to be involved in monitoring and managing their health.
  • There was effective staffing; clinicians were registered with the appropriate professional regulatory body and had opportunities for continuing professional development to meet the requirements of their professional registration.
  • Consent was sought and recorded before treatment and for information sharing; and the provider demonstrated a thorough understanding of the Mental Capacity Act 2005.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance.

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

The service used information about care and treatment to make improvements.

The service made improvements through the use of completed audits. Clinical audit had had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. Approximately 25% of the provider’s consultations were for concerns relating to sexual health. An important aspect of this is the advice given to patients about informing their partner or partners of their condition, a process referring to as contact tracing. Dr Cottrell carried an audit of patients’ records to see how often contact tracing had been recorded. The initial audit found that it had been recorded in 65% of cases. Dr Cottrell made changes to the record system to encourage clinicians to give and record contact tracing advice. A second cycle audit found that contact tracing advice had been recorded as given to the patient in 95% of cases.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation and appraisal.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. Where patients’ children received vaccinations, the staff completed entries in the child’s “red book” so that data was available to other services. Patients with long term conditions were managed by private consultants. We saw evidence of effective communication between the provider and the consultants.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service. However, most patient’s using the service did not have an NHS GP.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example, where patients with sexually transmitted infections (STIs) were unsure about informing their partner or partners of their condition, they were referred to “Umbrella” a service that undertook this this service confidentially.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified and highlighted to patients.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. In our inspection of August 2018, we asked the provider to review the training requirements and updates for clinicians in relation to consent and the Mental Capacity Act 2005. At this inspection we saw that the provider had addressed those concerns.
  • The service monitored the process for seeking consent appropriately.



Updated 12 November 2019

  • Patients indicated through feedback they were listened to, treated with respect and kindness; and were involved in the discussion of their treatment options, which included any risks, benefits and costs.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received and the feedback from patients was positive about the way staff treated people.
  • Staff understood patients’ personal, cultural, social and religious needs. There had been training for staff including reception staff on the importance of recognising and using trans-inclusive language. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. In our inspection of August 2018, we asked the provider to review the necessity for interpretation services for patients whose first language is not English. At this inspection we saw that the provider had addressed those concerns. For example, the provider had a telephone translation service available.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 12 November 2019

  • The service was responsive and ensured there was timely access to the service with a range of appointment times available.
  • The provider handled complaints in an open and transparent way, the complaint procedure was readily available for patients to read in the reception area

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. About 25% of the practice appointments related to sexual health. The provider recognised that how they communicated with these patients might be particularly sensitive. All patients could specify how they wanted the practice to communicate with them, whether by telephone or email. They could specify when they wished to be contacted, for example, only after a certain time.
  • The practice offered anal Papanicolaou smear testing particularly for men who have sex with men. This test is an effective screening tool for anal cancer. This service is not generally available of the NHS.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. The clinic was on the ground floor and the consulting room was accessible to patients in wheelchairs.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment. For example, patients, particularly those with suspected sexually transmitted infections, were keen to hear the results of any tests. These were usually completed on the same day. Patients had a secure log in to their own patient record and could see the results of the tests on line. Dr Cottrell was available by telephone to help patients interpret the tests if necessary.
  • Waiting times, delays and cancellations were minimal and managed appropriately. The provider’s target was that patients should not wait for more than five minutes, if this happened the reception staff were instructed to inform Dr Cottrell. The appointment schedule allowed for five minutes between each consultation to try and avoid sessions running late.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use. Appointments could be made on-line, by e-mail or by telephone.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had a complaint’s policy and procedure. There had been no formal complaints during the previous year. Staff were told to inform Dr Cottrell where there was any sign that a patient might have a sense of grievance. In such cases Dr Cottrell contacted the patient to discuss the issue and allay any concerns that might have been developing.



Updated 12 November 2019

  • There was a management structure in place and the provider had the managerial capacity to run the service.
  • There were clinical governance and risk management structures which monitored performance. There was a pro-active approach to identify safety issues and the provider acted on this information to make improvements in procedures where needed.
  • Risks to patients and staff were assessed and the provider audited areas of their practice as part of a system of continuous improvement.
  • The views of patients were sought, and policies and procedures were in place to support the safe running of the service.
  • There was a focus on improvement within the service.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities. For example, there were plans for the provider to add to the range of services at the clinic and staff were being trained for this.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. For example, a person had been booked for a vaccination when they were too young to receive it. The vaccination had not been given as a staff member had checked the person’s age. However, the incident was treated as a “near miss”. The provider had made changes to the booking system to help prevent a similar incident happening.

  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary. For example, a member of the staff team had expressed an interest in developing their competency in dealing with sexually transmitted infections and was booked onto an appropriate course in the near future. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. There were regular meetings between all staff. There was a daily meeting where the days tasks were discussed. There were meetings between Dr Cottrell and the staff, these had identified for example, training and development opportunities. We saw that these discussions had resulted in staff receiving the development that had been identified.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. In our inspection of August 2018, we asked the provider to review their oversight of health and safety risk assessments for the premises. Since then the provider had worked closely with the building’s leaseholder. They now had a much clearer picture, and records, of the how overall safety and risk assessments, such as that for Legionella, were managed across the site.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. Patients were able to leave feedback using an electronic device at the practice or could do so anonymously on the practice website.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings. For example, there was management training available to the registered manager designate.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. Recent continuous professional development (CPD) learning had included sessions with consultants on various musculoskeletal injuries and treatments common to sporting injuries. This was relevant to demographic of the patients seen at the practice.
  • The service has signed up to “Pride in Practice”. This is a quality assurance and social prescribing programme that aims to strengthen and develop primary care services' relationships with their lesbian, gay, bisexual and trans (LGBT) patients. As part of this process an introductory talk was scheduled for a forthcoming CPD session.