The Care Quality Commission
  • Doctor
  • GP practice

The Cedars Surgery Also known as Cedars surgery

Overall: Good read more about inspection ratings

87 New Bristol Road, Worle, Weston Super Mare, Avon, BS22 6AJ (01934) 515878

Provided and run by:
Dr Michael Pimm

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 Cedars 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 The Cedars Surgery, you can give feedback on this service.

20 February 2020

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at The Cedars Surgery on 20 February 2020 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection in July 2017.

This inspection focused on the following key questions:

  • Are services effective?
  • Are services responsive?
  • Are services well led?

Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:

  • Are services safe? (Good)
  • Are services caring? (Good)

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 provided the practice with Care Quality Commission feedback cards prior to the inspection and we received 19 completed cards. Patients were generally positive about the practice staff, their experiences, and the care and treatment they received.

We have rated this practice as good overall; good for providing effective, responsive and well led services; Requires Improvement for the population group which includes working age people (including those recently retired and students) and good for the remaining population groups because:

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
  • Staff worked together and with other organisations to deliver effective care and treatment.
  • There was compassionate, inclusive and effective leadership at all levels. This included working with and supporting the practice Patient Participation group (PPG).
  • The practice had a clear vision and set of values that prioritised quality and sustainability.
  • The practice had a culture that drove high quality sustainable care.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • There were clear and effective processes for managing risks, issues and performance.

Although we did not find any beaches of regulation on this inspection, we did see one area where the provider should make improvements. This was to:

  • Monitor arrangements for recording consent to include the administration of joint injections.
  • Continue monitoring the uptake of cervical screening in line with national guidance.
  • Continue monitoring the effectiveness and need for two week wait referrals.

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

18 July 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

The Cedars Surgery has recently combined with two other local practices, Worle Medical Practice, which is now a branch surgery known as Worle Health Centre; and The Village Surgery (which had become a branch surgery but the site has now closed). This inspection report relates to the Cedars Surgery and Worle Health Centre sites which were both visited during this follow up inspection.

We carried out an announced comprehensive inspection at The Cedars Surgery on 8 September 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for The Cedars Surgery on our website at www.cqc.org.uk.

We also carried out a an announced comprehensive inspection at Worle Medical Practice on 7 January 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the January 2016 inspection can be found by selecting the ‘all reports’ link for Worle Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused follow up inspection carried out on 18 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections in January 2016 and September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • A fire risk assessment had been completed, documented and actions identified had been addressed, including carrying out regular fire drills.
  • A system had been implemented to ensure all Patient Group Directions are current, authorised and signed before vaccinations are provided to patients.
  • Arrangements for infection prevention and control (IPC) had been reviewed, an IPC audit had been completed and identified actions had been addressed for both sites.
  • Arrangements for the security of blank prescription stationery had been reviewed to ensure security when clinical rooms are unoccupied.
  • Personnel files had been reviewed and updated to include records of all appropriate recruitment checks undertaken prior to employment.
  • Arrangements had been reviewed to ensure all MHRA (Medicines and Healthcare products Regulatory Agency) safety alerts are recorded and addressed.
  • Arrangements for temperature checks of vaccine storage had been reviewed to ensure recording is complete.
  • We saw records confirming all staff had received up to date training in basic life support, safeguarding and fire safety.
  • Arrangements for quality improvement such as clinical auditing were in place.
  • Arrangements had been reviewed to ensure patient consent is recorded in medical records.
  • Arrangements were in place to ensure that patient records are secure to prevent unauthorised access.
  • Arrangements for business planning and strategic development had been reviewed and we saw evidence of improved structure, documentation and cohesion in the management of the practice.
  • Support arrangement had been reviewed to ensure that Independent Prescribers receive mentorship and support from the medical staff for this extended role.
  • The process for triage of requests from patients for a home visit had been reviewed to ensure there is no undue delay.
  • Arrangements to identify and support military veterans had been reviewed and were in line with the military veteran’s covenant.
  • GP staffing levels had improved and we saw evidence that the nursing team and have access to clinical support and advice should a medical emergency arise during the practice opening hours.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Cedars Surgery on 8 September 2016. Overall the practice is rated as requires improvement.

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 managed. However, we found that some systems were not implemented well enough to keep patients safe.
  • The practice utilises the Map of Medicine system to access up to date clinical pathways and make referrals; and we saw evidence of monthly safety searches for high risk medication such as disease modifying anti-rheumatic drugs (DMARDS).
  • We saw evidence of responding to patients’ needs such as longer appointments and extended opening hours.
  • 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 said 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. Staff told us there was an open, honest and positive culture in the practice and we saw that access to all policies and procedures was readily available to all. However, the practice did not have a documented business plan and business development meetings were not minuted.
  • The practice proactively sought feedback from staff and patients, which it acted on. We saw evidence of forward thinking and involvement in local initiatives and developments for the benefit of patients. For example, we saw evidence of consultation with staff and patients regarding changes such as the sharing of information on a potential practice merger.
  • 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 patient records are secure to prevent unauthorised access.
  • Ensure that a fire risk assessment is carried out, documented and any actions identified are addressed, including ensuring regular fire drills are carried out.
  • Implement a system to ensure all Patient Group Directions are current, authorised and signed before vaccinations are provided to patients.
  • Ensure all staff receives up to date training in basic life support, safeguarding and fire safety.
  • Ensure that arrangements for infection prevention and control are reviewed, recorded and any identified actions are addressed for the Village Surgery site.

The areas where the provider should make improvement are:

  • Review arrangement to ensure that Independent Prescribers receive mentorship and support from the medical staff for this extended role.
  • Review the arrangements for security of blank prescription paper for times when clinical rooms are unoccupied.
  • Review personnel files to ensure that records of all appropriate recruitment checks undertaken prior to employment were included.
  • Review arrangements to ensure all MHRA (Medicines and Healthcare products Regulatory Agency) safety alerts are recorded and addressed.
  • Review arrangements for temperature checks of vaccine storage and ensure recording is complete.
  • Review the arrangements for quality improvement such as clinical auditing.
  • Review the arrangements to ensure patient consent is recorded in medical records.
  • Review the process to triage requests from patients for a home visit to ensure there is no undue delay.
  • Review arrangements for business planning and strategic development to develop more structure, documentation and cohesion in the management team.
  • Review arrangements to identify and support military veterans, in line with the military veteran’s covenant.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice