The Care Quality Commission
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Archived: Freezywater Primary Care Centre

Overall: Good read more about inspection ratings

2b Aylands Road, Enfield, Middlesex, EN3 6PN 0844 387 9994

Provided and run by:
Freezywater Primary Care Centre

Important: The provider of this service changed. See new profile

All Inspections

4 March 2020

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: effective, responsive and well led.

The practice was first inspected in November 2013. This was an unrated inspection under the CQC’s previous inspection framework. At that inspection the practice was issued with compliance notices for Regulation 12 (cleanliness and infection control) as there was no effective inspection control system in place, and Regulation 19 (complaints) as the practice did not have an effective complaints procedure in place. A Follow up inspection took place in May 2014 where the practice was found to be meeting the standards for Regulation 19. At a follow up inspection in September 2014 the practice was found to be meeting the requirements for Regulation 12.

The first rated inspection took place on 7 August 2016. The practice was rated good for all key questions and population groups and good overall.

At this inspection (4 March 2020), 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 good for providing an effective, responsive and well-led service because:

  • The practice had not met national targets for the cervical cancer screening programme, however measures had been put in place to improve the results of the programme.
  • The practice had not met World Health Organisation (WHO) targets for the childhood immunisation programme but was working on a number of steps to improve this.
  • The practice organised and delivered services to meet patients’ needs. 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.

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

  • Take action to improve the uptake for the childhood immunisation programme.
  • Take action to improve the uptake for the cervical cancer screening programme.
  • Consider recording exception rates for the Quality Outcome Framework (QOF).
  • Consider ways to improve results from the national GP patient survey.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

17 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice


We carried out an announced comprehensive inspection at Freezywater Prmary Care Centre on 17 August 2016. 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 recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients found it difficult to access the practice via telephone to make an appointment; however, they were able to access a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Review procedures for authorising Patient Specific Directions’s (PSD’s) to ensure all staff are administering vaccines in line with legislation.

  • Review arrangements in regard to the patient participation group to ensure that the group remains effective and clear about their role in supporting theevaluation of quality and delivery of services.

  • Regularly review telephone access to the practice to reduce untimely delays in accessing appointments and dealing with requests.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

2 September 2014

During an inspection looking at part of the service

This visit was a follow up to our inspection of the practice on 7 May 2014.

We had found there was not an effective system in place to assess the risk of health care associated infections and to prevent, detect and control their spread. We also found no cleaning specification or schedule linked to any formal risk assessment of the practice in relation to infection prevention and control (IPC). Additionally, although the practice had introduced a regular log relating to some aspects of infection prevention and control, it did not meet the requirements set out in the Department of Health Code of Practice on the Prevention and Control of Infections and Related Guidance.

Following our inspection in May 2014 we served the practice with a warning notice under Section 29 of the Health and Social Care Act 2008 requiring the practice to be compliant with the requirements of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 by 1 August 2014. We carried out this visit to check that the requirements had now been met.

We found that the practice had taken appropriate action and was now compliant with the regulation.

7 May 2014

During an inspection looking at part of the service

At our last inspection in November 2013 we found that the provider was non-compliant with standards relating to infection control and the management of complaints.

During our November 2013 inspection we found that cleaning of the premises did not meet essential standards. Cleaning schedules did not contain information on the frequency of cleaning, or what was to be cleaned, how it was to be undertaken and what equipment was to be used. We found that no risk assessments or auditing had been undertaken to assess the level of risks associated with the environment and no action plan was in place to meet essential requirements.

At this inspection we reviewed infection control arrangements. We found no cleaning specification or schedule linked to any formal risk assessment of the practice in relation to infection prevention and control. We found that although the provider had introduced a regular log relating to some aspects of infection control and cleanliness procedures, it did not meet the requirements as set out in the code of practice. We also found that the provider had not carried out all the tasks required by the annual infection control programme for primary medical care.

We looked at standards in relation to quality assurance at the last inspection in November 2013. We found that the practice was non- compliant with complaints management. We found that the complaints policy and protocol did not outline expected or appropriate timescales for acknowledging and investigating complaints.

At this inspection we looked at the practice's updated complaints policy which detailed a clear protocol for acknowledging any complaints within a timeframe of three working days and a commitment to conducting investigations within ten working days following the date of acknowledgement of the complaint. This policy was now in line with best practice.

26 November 2013

During a routine inspection

We spoke with eight patients attending appointments at the practice on the day of our visit. They told us they were happy with the care and treatment provided. For example, one patient told us "It's a good practice, doctors are friendly and they listen to your concerns in a genuine way." Another patient said "I feel reassured now as I had been worrying. They are thorough and always send me for a test when I need to be checked thoroughly." Patients generally felt they were understood and felt listened to and supported by clinical staff. Everyone told us their privacy and dignity had been respected by staff. Patients said it was relatively easy to make an appointment at a convenient time.

Patients told that they trusted the GP's and nurses at the practice. Staff were able to demonstrate the knowledge and skills needed to protect children and adults from possible abuse.

Patients told us the practice was always very clean and we saw there were systems in place to reduce the risk of infection. However, although staff told us they were aware of infection control risks there had been no formal risk assessment of the practice in relation to infection prevention and control. As a result the provider could not be assured that people were protected against the risk of exposure to a health care associated infection.

There were appropriate arrangements for the management of medicines and there were procedures for dealing with emergencies including having emergency medication available.

There was a complaints policy available but it did not outline expected timescales for acknowledging and investigating complaints or detail which other organisations were available should a complainant not be satisfied with the response provided by the practice. Three out of four complaints had not been acknowledged in a timely way.