Waterbeach Surgery

Primary Medical Services · East

Overall Rating
Requires Improvement Last inspected 9 December 2021
Domain Ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement

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1 must-do action
2 should-do actions

Must-Do Actions (1)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Well-led
Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare
Regulation 17 HSCA (RA) Regulations 2014 Good governance
Wefoundaninconsistencyinthereviewingandcodingofmedicinereviewsundertaken.Therewere1008medicines reviewsthathadnotbeenfullydocumentedornot undertakeninthepast12months. Wefoundsomegapsinthemonitoringandclinical oversightofallclinicalstaffperformance,andmedical recordkeeping.Wefoundexamplesofpoor documentationwithmedicalrecords.Wefoundalack ofdetailwhichdidnotensureotherhealth professionalsorpatientsreadingthenoteswould understandorhavealltheinformationtheymay requiretoassessandtreatthepatient. Wefoundexamplesofpoorcodinginrespectof patientswithchronickidneydisease.Wefoundan estimatedcalculationhadbeenrecordedandnotan actualcalculation.Thiswasbecausetherecorddidnot containanuptodateweightofthepatient.

Should-Do Actions (2)

Recommended improvements to enhance service quality.

Should Do
Responsive
Continuetomonitorandimprovepatientexperiencerelatingtoaccesstothesurgery.
Should Do
Effective
Continuetomonitorandimproveuptakeforcervicalscreeningprogramme.
Location Details
CQC ID: 1-10438797030
Local Authority: Cambridgeshire
Region: East
Inspection Report
Type: Comprehensive inspection
Date: 9 December 2021
Rating: Requires Improvement
Actions: 1 must-do , 2 should-do
AI-extracted 17 Feb 2026