The Care Quality Commission
  • Doctor
  • GP practice

The Petersfield Medical Practice

Overall: Good read more about inspection ratings

25 Mill Road, Cambridge, Cambridgeshire, CB1 2AB (01223) 350647

Provided and run by:
The Petersfield Medical Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Petersfield Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Petersfield Medical Practice, you can give feedback on this service.

30 March 2022

During a routine inspection

We carried out an announced comprehensive inspection at The Petersfield Medical Practice on 30 March 2022. Overall, the practice is rated as good.

The ratings for each key question are:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 31 May 2017, the practice was rated Good and for all key questions.

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

Why we carried out this inspection

This inspection was a comprehensive inspection. We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 Good

We found that:

  • The practice provided care in a way that kept patients safe and protected them from harm.
  • 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. 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-centre care.
  • The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Although the practice and staff told us there was supervision and competency checks for all staff, we did not see this was always formally recorded for future and proactive learning.
  • The practice had been challenged with some staff changes and difficulties in recruiting which impacted on summarising of patient notes which had resulted in a backlog.
  • The process for conducting meetings was not always structured, this did not assure us that learning was always shared effectively.
  • The practice was in transition with building work.Therefore, some action plans from risk assessments were still outstanding.

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

  • Improve the system and process in place to provide regular feedback and learning opportunities in a way that will support learning and improvements for all clinical staff.
  • Review and improve the system and process to gain feedback from patients and staff to make improvements to services
  • Continue to improve the uptake of cervical screening.
  • Improve the use of templates in meetings to provide structure and consistency to be assured learning is shared.
  • Continue to develop an action plan to ensure summarisation of notes is conducted in a timely way.
  • Continue to identify and offer support to carers within the practice.
  • Continue to identify, contact and assess patients who are eligible for NHS health checks.

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

31 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Petersfield Medical Practice on 10 January 2017. The overall rating for the practice was good, with requires improvement for providing safe services. The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for The Petersfield Medical Practice on our website at www.cqc.org.uk.

We undertook a desk-based focused inspection to check they had followed their action plan and to confirm they now met legal requirements in relation to the breach identified in our previous inspection on 10 January 2017. This report only covers our findings in relation to those requirements.

Overall the practice is now rated as good.

Our key findings from this inspection were as follows:

  • The practice had an effective recruitment system in place to ensure that staff had the appropriate knowledge, skills and experience for their roles and that identity checks were completed prior to employment.
  • Furthermore, the practice had introduced occupational health screening for new staff to ensure that they were capable of performing the tasks required of the role they were employed to perform.
  • A formal process for discussing significant events had been introduced to promote learning from incidents. For example, significant events were now shared at weekly practice meetings.
  • The practice had worked with the local infection control lead to formulate an action plan in response to the practice’s regular infection control audits.
  • Health and safety risk assessments had been undertaken for the premises.
  • An induction framework had been developed for all new staff, and Mental Capacity Act (2008) training had been undertaken by existing staff.
  • The practice monitored patient feedback received online and through the Patient Participation Group. They attended regular Federation and Clinical Commissioning Group locality meetings in order to understand how they could best meet patients needs and improve access where appropriate.
  • The practice had created a bespoke 'Carers Pack' to be given to all patients who were carers.
  • Information about how to make a complaint had been added to the practice website and made available on site.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Petersfield Medical Practice on 10 January 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and investigating significant events. Further improvement could be made to recording significant events to ensure that their progress could be tracked more easily.

  • Risks to patients were assessed and well managed although general health and safety risk assessments needed to be strengthened.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patient comments we received indicated that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, results of the national GP patient survey did not always align with these views.
  • Information about services offered by the practice was available along with further information about a range of local services. A complaints process was clear and well managed although there was limited information available to support patients who had a concern or complaint about their care.
  • Patient feedback indicated that they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. Patients also told us staff took time to listen to their needs, were kind and caring.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on. However, further developments were needed to strengthen systems for receiving patient feedback to help inform quality improvements and improve patient experience.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure that the recruitment process is followed and records are held to demonstrate that;

    • staff have appropriate knowledge, skills and experience

    • identity checks have been completed

    • staff by reason of their health, are capable of performing the tasks required of the role they are employed to perform.

The areas where the provider should make improvement are:

  • Improve the recording of significant events so that information can be easily tracked.

  • Develop infection control action plans in response to audits so that progress can be monitored.

  • Review the general health and safety risk assessments to include appropriate detail about the identified risks and any actions taken to mitigate these.

  • Review the induction process for new staff and review staff awareness of the Mental Capacity Act 2008.

  • Improve systems for gathering and responding to patient feedback including the national GP patient survey. This should include actions in response to patients who are dissatisfied with the practice’s opening times.

  • Improve systems used to identify patients with caring responsibilities so that appropriate levels of support may be offered.
  • Review patients’ access to information on how to raise a concern or complaint.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice