This practice is rated as Requires Improvement overall. (Previous rating 05 2015 – Good)
The key questions at this inspection are rated as:
Are services safe? – Requires Improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires Improvement
We carried out an announced comprehensive inspection at Cedar Practice on 19 July 2018, as part of our inspection programme.
At this inspection we found:
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There was no evidence on the personnel file of one member of the clinical team to show that they had received a Disclosure and Barring Service (DBS) check or Criminal Records Bureau (CRB) check, nor was there a suitable risk assessment for lack of a DBS or CRB check.
- The practice had some systems to manage risk so that safety incidents were less likely to happen. However, it had not undertaken a recent fire risk assessment or a health and safety risk assessment. The practice subsequently provided us with evidence that it had carried out a suitable fire safety risk assessment and a health and safety risk assessment. The health and safety risk assessment contained an action plan but did not specify dates for rectification or review of any issues identified.
- The practice had not carried out an infection prevention and control audit since 2016. Following the inspection, the practice prepared and provided us with an infection prevention and control audit. However, it did not include an action plan for any non-compliant issues, or dates by which it would rectify or review any issues.
- There was no electrical safety policy or business plan. During our inspection the practice prepared and implemented an appropriate electrical safety policy and business plan.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff treated patients with compassion, kindness, dignity and respect.
- Patients reported that they could access care when they needed it.
- The practice used information technology systems to monitor and improve the quality of care.
- Structures, processes and systems were not consistently effective to support good governance and management.
The areas where the provider must make improvements are:
- 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:
- Review and consider what action it can take to increase uptake of childhood immunisations.
- Review and consider ways to increase uptake of its cervical, breast and bowel cancer screening programmes for the benefit of patients.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.