Source · CQC inspection

Waterbeach Surgery

Type Primary Medical Services Region East Last inspected 9 Dec 2021

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Requires Improvement

Earlier inspection findings

pre-2024 framework · 1 must-do 2 should-do

Must-do actions (1)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 1

Must do

Well-led

Establisheffectivesystemsandprocessestoensuregoodgovernanceinaccordancewiththefundamentalstandards ofcare

Regulation: 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 action 1 of 2

Should do

Responsive

Continuetomonitorandimprovepatientexperiencerelatingtoaccesstothesurgery.

Should-do action 2 of 2

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