The Care Quality Commission
  • Doctor
  • GP practice

Arbury Road Surgery

Overall: Good read more about inspection ratings

114 Arbury Road, Cambridge, Cambridgeshire, CB4 2JG (01223) 364433

Provided and run by:
Arbury Road Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Arbury Road Surgery 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 Arbury Road Surgery, you can give feedback on this service.

20 December 2021

During an inspection looking at part of the service

We carried out an announced desk-based review of Arbury Road Surgery on 20 December 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Not inspected

Effective -Good

Caring - Not inspected

Responsive - Not inspected

Well-led - Not inspected

Following our previous inspection in June 2019 the practice was rated Good overall and for all key questions except for providing effective services.

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

Why we carried out this review

This desk-based review was to follow up on the breach of regulation and areas where the provider ‘should’ improve which were identified at our previous inspection. We found the required improvements had been made and the practice is now rated as good for providing effective services.

How we carried out the review

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 reviews differently.

This review was carried out in a way which did not require a site visit. 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
  • Requesting evidence from the provider

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.

The practice remains rated as Good overall

We found that:

  • Despite the COVID-19 pandemic the practice had improved the uptake for cervical cancer screening and baby immunisations.
  • The practice had reviewed their systems and processes to ensure patients who may be experiencing poor mental health received appropriate and timely care and treatment.
  • The practice had been proactive in offering and undertaking structured reviews for patients with a learning disability. The practice had increased the number of these that were completed in the patient’s own home where the patient was more comfortable.
  • The practice regularly reviewed their prescribing data and information received from the CCG. Communication and monitoring within the practice had been increased to ensure all clinical staff were prescribing appropriately and safely.

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

30 May 2019

During an inspection looking at part of the service

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Safe
  • Effective
  • Well-Led

At the last inspection in June 2018, we rated the practice as requires improvement for providing safe services because:

  • The infection prevention and control policy was brief and missing key information such as waste and sharps management. There was an incident at the practice involving a needlestick injury which was handled incorrectly and potentially could have been avoided if clear policies and procedures were in place.
  • The practice employed an external cleaning company but there was no documentation to evidence the cleaning that took place within the practice. We found on the day of the inspection that the cleanliness of treatment rooms was not to an acceptable standard. We noted there was dirt and dust on the floor in two treatment rooms. This was also highlighted in the audit completed one week prior to our inspection but no action had been taken to remedy this.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is 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.

The practice was rated as requires improvement for providing effective services because:

  • The practice’s uptake of cervical screening was below the 80% Public Health England target rate and below CCG and England averages.
  • The practice’s uptake of childhood immunisations was below the 90% World Health Organisation target rate and the practice told us this rate had reduced further in unpublished data.
  • The practice’s performance for outcomes for patients experiencing poor mental health was mixed and the practice told us this rate had reduced further in unpublished data. The practice’s exception reporting rate for mental health indicators was also higher than the CCG and England averages.
  • The practice had only completed 4 health checks out of 79 eligible patients diagnosed with a learning disability

We also rated the practice as good for providing safe, caring, responsive and well-led services.

The area where the provider must make improvements are:

  • Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences

The areas where the provider should make improvements are:

  • Continue to review the prescribing of antibiotic items to ensure safe and appropriate prescribing.

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

14/05/2018

During a routine inspection

This practice is rated as Good overall. At the previous inspection in June 2015 the

practice were rated as good overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Arbury Road Surgery on 14 May 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. We saw evidence that learning points were discussed in management meetings and staff we spoke to were aware of these.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice’s performance in relation to the Quality Outcome Framework (QOF) results was in line with the Clinical Commissioning Group (CCG) and national averages.
  • The overall exception reporting rate was above the CCG and national averages. We noted that the practice had incorrectly coded some patients’ records, which had led to the patients being incorrectly included in the exception reporting rate.
  • The practice’s uptake for cervical screening was below the target for the national screening programme. The practice advised due to the multilingual demographic of the practice population, the practice had difficulties in patients attending for cervical screening due to uncertainty over the procedure. We could not find evidence that the practice had made further engagement with patients of this group to educate and encourage attendance.
  • There were comprehensive risk assessments in relation to building safety issues such as fire safety and health and safety.
  • The infection prevention and control policy was brief and missing key information such as waste and sharps management.
  • The practice employed an external cleaning company, but there was no documentation to evidence the cleaning that took place within the practice. We found on the day of the inspection that the cleanliness of treatment rooms was not to an acceptable standard. We noted there was dirt and dust on the floor in two treatment rooms. This was also highlighted in the audit completed one week prior to our inspection but no action had been taken to remedy this.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Staff told us that they were happy to work at the practice and felt supported by the management team. Staff told us they were encouraged to raise concerns and share their views.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Results from the July 2017 national GP patient survey were in line with and above local and national averages. Feedback from patients we spoke with and received comments from supported these findings.
  • We saw evidence that complaints were handled effectively, trends were analysed and lessons learned and distributed amongst relevant staff.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients

The areas where the provider should make improvements are:

  • Review and improve the uptake of cervical screening.
  • Review and improve the coding of patient records to ensure reviews are carried out appropriately.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

15 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We visited Arbury Road Surgery on the 15 April 2015 and carried out a comprehensive inspection. The overall rating for this practice is good. We found that the practice provided a safe, effective, caring, and responsive service. Improvements were needed to ensure that robust governance process were in place in relation to policies.

We examined patient care across the following population groups: older people; those with long term medical conditions; mothers, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health. We found that care was tailored appropriately to the individual circumstances and needs of the patients in these groups. Our key findings were as follows:

  • All patients at the practice were registered with a named GP and we saw evidence of continuity of care.
  • Patients were satisfied with the opening hours. They reported that it was easy to get through on the telephone to make an appointment and appointments were made at convenient times.
  • Patients felt they were treated with dignity, care and respect. They were involved in decisions about their care and treatment.
  • The practice addressed patients’ needs and worked in partnership with other health and social care services to deliver individualised care.
  • The practice had good facilities and was well equipped to treat patient and meet their needs.
  • The needs of the practice population were understood and services were offered to meet these. Feedback from the care homes where patients were registered with the practice was positive.
  • Staff were clear of their roles and responsibilities and followed available guidance. However improvements were needed to ensure there was a robust process in place for the approval, dissemination and review of policies.

However, there were also areas of practice where the provider needs to make improvements. In addition the provider should:

  • Identify areas where oxygen is stored and mark them with 'hazardous substance' notices.
  • Ensure the process for checking that identified actions had been undertaken following significant events and complaints is completed and documented.
  • Ensure all staff attend infection control training.
  • Review and update the disaster recovery plan.
  • Ensure all staff receive an annual appraisal.
  • Provide information on the complaints policy so that it can be easily and independently accessed by patients.
  • Ensure there is a robust process for the approval, dissemination and review of practice policies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 November 2013

During a routine inspection

During our inspection on 28 November 2013 we spoke with 18 people who were either waiting to attend an appointment, or were collecting a prescription for medication. Overall, they told us they were very satisfied with the service provided by the surgery and made comments about the positive and friendly attitude of GPs, the nurses and the reception staff they had spoken with. One family group we spoke with who were attending an appointment said, "They are all polite and helpful. We are lucky to have such a good surgery near to us."

We found that people were well informed and suitably involved in the detail and information they required about their health and in the planning of their healthcare. Care records reflected the health support advice and treatment that had been provided to people.

We found that people were protected from abuse and harm because the provider had taken suitable steps to ensure staff could respond appropriately should abuse be suspected or alleged.

Staff were supported to carry out their roles with competency. Clinical staff had been supported to continue their professional development and GPs had ensured they were able to maintain their professional development and status of a teaching practice approved by the NHS Health Education East of England that supports medical trainees in the region.