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Inspection Summary


Overall summary & rating

Good

Updated 24 December 2018

We carried out an announced comprehensive inspection of The Cedars Surgery on 27 February 2018. The practice was rated as good overall with all domains rated as good, except for Well led which was rated as requires improvement. During the February 2018 inspection we found governance concerns with staff recruitment files, risk assessments associated with background checks for staff and complaints processes. In addition, we advised the practice to review their exception reporting and improve their childhood immunisation uptake figures.

We undertook an announced focused follow up inspection on 12 December 2018 to follow up on the breach of regulation identified during the previous inspection.

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 and other organisations.

We rated the practice as good for providing well-led services because:

  • Disclosure and barring service (DBS) risk assessments had been undertaken for all staff groups. This enabled the practice to determine if a new DBS check was required or not.
  • Recruitment files had been reviewed and updated with relevant information. There was an embedded process for ensuring background checks were undertaken on new staff who commenced employment with the practice after the last inspection.
  • Complaints processes had been reviewed and updated. All complaints written responses contained details of the health ombudsman.

During the last inspection in February 2018, we found some areas where the practice should improve and reviewed these during the inspection in December 2018.

The GP partners had reviewed their exception reporting processes and identified some of the reasons behind non-attendance for reviews or screening. One of the GPs had been given protected time to review exception reporting monthly and any concerns or areas for improvement were highlighted to the lead GP for that indicator.

The quality outcomes framework (QOF) exceptions had reduced from 7% in 2016/17 to 5% in 2018/19. Specifically, cervical screening QOF exceptions had reduced from 24% in 2016/17 to 11% in 2017/18.

The nursing team and governance lead GP had reviewed their child immunisation uptake figures since the last inspection. We noted the 2017/18 figures from NHS England demonstrated the practice had achieved over 90% uptake for all four immunisation sub-indicators.

Since the last inspection the nursing team had instigated a checking procedure for new patients registering with the practice to determine if their immunisations were up to date and correctly recorded on the practice computer system.

The practice demonstrated they had embedded these processes and had appropriate governance structures in place to continue improving.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good
Checks on specific services

People with long term conditions

Good

Updated 19 April 2018

Families, children and young people

Good

Updated 19 April 2018

Older people

Good

Updated 19 April 2018

Working age people (including those recently retired and students)

Good

Updated 19 April 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 19 April 2018

People whose circumstances may make them vulnerable

Good

Updated 19 April 2018