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.
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:
We rated the practice as good for providing well-led services because:
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
This practice is rated as Good overall. (Previous inspection October 2016 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at The Cedars Surgery on 27 February 2018. We carried out this inspection to follow up on concerns raised at the previous inspection. Although there were no breaches of regulation, the practice was previously rated as requires improvement for providing Effective services.
At this inspection we found:
The areas where the provider must make improvements are:
The areas where the provider should make improvements are:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Cedars Surgery on 19 October 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The areas where the provider should make improvement are:
Chief Inspector of General Practice
During our last inspection we found concerns regarding staff awareness of safeguarding. The practice's recruitment procedures did not ensure all information required about employees was collected.
Staff confirmed that the background checks and information were requested from them before they began work. They told us they had received safeguarding training. Staff we spoke with were aware of their role in protecting patients from abuse.
We saw evidence that safeguarding training was delivered to staff. We saw documents which indicated that the service requested information on employees' previous employment. We saw that appropriate background checks were undertaken on staff.
Patients told us most staff provided them with clear explanations during consultations and treatment. One patient said "My GP is very good at making things clear." Another told us "The GPs are good with my children when I bring them."
Patients were satisfied with the care and treatment they received. Some stated they found appointments difficult to book, but all of the patients we spoke with said they were able to get appointments when they needed one. Care and treatment records were detailed and contained relevant information about ongoing health conditions.
Staff said their feedback was valued and considered in the running of the service. The provider had effective systems to monitor the quality and effectiveness of the service provided.
The provider had not taken all reasonable steps to ensure safeguarding awareness was provided to all staff through training or that their understanding of safeguarding was adequate.
Not all of the pre-employment checks for staff had been completed by the provider. As a result the provider could not be certain that all staff employed to undertake regulated activities were of good character and fit to perform their roles.