The Care Quality Commission
  • Doctor
  • GP practice

The Cedars Surgery

Overall: Requires improvement read more about inspection ratings

24 Marine Road, Walmer, Deal, Kent, CT14 7DN (01304) 373341

Provided and run by:
The Cedars Surgery

All Inspections

06 September 2023

During a routine inspection

We carried out an announced focused inspection at The Cedars Surgery. We conducted remote clinical searches on the practice’s computer system on 5 September 2023 and conducted an onsite inspection of the practice on 6 September 2023.

Following our previous inspection on 9 June 2022, the practice was rated as requires improvement overall as well as for providing safe and effective services, and good for providing responsive and well-led services. After our inspection in June 2022, the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with regulations.

The full report for the June 2022 inspection can be found by selecting the ‘all reports’ link for The Cedars Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection on 6 September 2023 to follow up the breaches of regulation found in our previous inspection in June 2022. Overall, the practice remains rated as Requires Improvement.

The key questions at this inspection are rated as:

Safe - Requires Improvement

Effective - Requires Improvement

Responsive – Requires Improvement

Well-led – Requires Improvement

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from the previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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 have rated this practice as Requires Improvement overall

We found that:

  • The practice had systems and processes to keep people safe and safeguarded from abuse.
  • Appropriate standards of cleanliness and hygiene were met.
  • The practice learned and made improvements when things went wrong.
  • The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Complaints were listened and responded to and used to improve the quality of care.
  • There was compassionate, inclusive and effective leadership at all levels.
  • There were systems and processes for learning, continuous improvement and innovation.
  • The practice organised and delivered services to meet patients’ needs.
  • Patients could not always access care and treatment in a timely way. We saw the practice was attempting to improve access.

We rated the practice as Requires Improvement for providing safe, effective, responsive and well-led services because:

  • Our clinical record searches found improvement was still required in relation to the safe management and monitoring of some long-term conditions, high-risk medicines and medicine safety alerts.
  • Improvements in processes for managing risks, issues and performance were still required.
  • Improvements were required in relation to patient satisfaction with access to services. Whilst we recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback.

We checked the areas where the provider should make improvements from our last inspection in June 2022 and found:

  • The provider had a comprehensive programme of quality improvement activity.
  • The provider had a system to monitor the outcome of plans to improve performance relating to the uptake of cervical cancer screening.
  • New systems to monitor staff personnel files and staff training had been fully embedded.

At this inspection in September 2023, we found there continued to be breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Take steps to monitor and improve screening uptake, specifically, cervical cancer screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

10 June 2022

During an inspection looking at part of the service

We carried out an announced inspection at The Cedars Surgery. We conducted remote clinical searches on the practice’s computer system on 9 June 2022 and conducted an onsite inspection of the practice on 10 June 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services responsive? - Good

Are services well-led? – Good

Overall, the practice is rated as Requires Improvement.

The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Following our previous inspection on 19 April 2016, the practice was rated Good overall and for Safe, Effective, Responsive and Well-led. The practice was rated as Outstanding for Caring.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Cedars Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a focused comprehensive inspection to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection focused on the following:

  • Are services safe?
  • Are services effective?
  • Are services responsive in relation to access?
  • Are services well-led?

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 have rated this practice as Requires Improvement overall.

We found that:

  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • There were systems and processes for learning and continuous improvement.
  • Published results showed the childhood immunisation uptake rates for the vaccines given were above the 95% World Health Organisation target.
  • The provider was aware of published performance data relating to cervical cancer screening and was continuing to take action to improve uptake by relevant patients.
  • The provider learned and made improvements when things went wrong.
  • Appropriate standards of cleanliness and hygiene were met.
  • The practice always obtained consent to care and treatment in line with legislation and guidance.
  • The practice involved staff to sustain quality and sustainable care.
  • There was compassionate, inclusive and effective leadership at all levels.
  • Improvements were required in relation to the management and oversight of staff personnel files, for example, staff immunisations.
  • There was limited monitoring of the outcomes of care and treatment.
  • Staff had the skills, knowledge and experience to carry out their role.
  • Due to the pandemic, protected learning time for staff was limited.
  • Improvements were needed for the process of monitoring patients’ health in relation to the use of some high-risk medicines.
  • Systems for acting on safety alerts were not always effective.
  • Patients’ needs were not always assessed, and care, as well as treatment, were not always delivered in line with current legislation, standards and evidence-based guidance.
  • There were processes for managing risks, issues and performance. However, these were not always effective.

The areas where the provider must make improvements are:

  • Ensure care and treatment of patients is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue to implement and monitor the outcome of plans to improve performance relating to the uptake of cervical cancer screening.
  • Continue to strengthen the monitoring and oversight of staff personnel files, for example, staff immunisations.
  • Continue to strengthen the monitoring and oversight of staff training.
  • Continue to use information to make improvements to care and treatment, by way of clinical audits.

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

19 April 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 19 April 2016. Overall the practice is rated as good.

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 for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • The practice was a training practice and provided mentoring for trainee GPs and paramedic practitioners. The practice also provided placements for apprentice non-clinical staff.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • There was an active patient participation group (PPG) which worked with the practice to provide several support groups for patients and carers.
  • 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 clear leadership structure and staff felt supported by management. The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice:

  • The practice had developed an extensive resource folder for patients with a learning disability. This could be used to assist communication during consultations and reduce barriers for patients who found it hard to use or access services.
  • The practice was empowering patients by engaging with the patient participation group (PPG) and working in partnership with them to improve services and outcomes for patients and patients who were also carers.
  • The PPG and the practice were working together to provide a support group for patients with type two diabetes to provide a forum for patients to share their experiences and explore alternative avenues for support and resources.
  • The practice was working with the PPG to provide a support group for patients who were also carers for people with dementia.
  • There was an active patient participation group that conducted bi-monthly ‘walk about’ sessions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice