We carried out an announced focussed inspection at Cedar Practice on 3 January 2019 to follow up on issues we found at our last inspection in July 2018. A copy of our pervious inspection report can be found by going to https://www.cqc.org.uk/location/ 1-572223055 and selecting the Reports tab.

In addition to the areas which were identified for improvement under the key questions of providing effective and well-led services, we also said the practice should make improvements in the following areas:

• 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.

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.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

We found that:

• The practice showed us its unpublished, and unverified, performance data for the year to date (2018-19) which showed that it had already met the minimum 90% performance target for uptake of childhood immunisations, with three months left to run in the screening programme.
• The practice provided us with evidence of the additional actions it had taken to improve uptake of its cancer screening programmes for cervical, breast and bowel cancer. This had resulted in improvements, for example, by the beginning of January 2019, 79% of eligible patients had undergone cervical screening, with three months left to run in the practice’s screening programme.
• The practice had undertaken a health and safety risk assessment and prepared an action plan for identified issues, however it had not included completion dates in the action plan to record issues that had been remedied.
• The practice ensured that the clinician who had not previously received an appropriate Disclosure and Barring Service (DBS) check or Criminal Records Bureau (CRB) checks, had received one since our last inspection.
• It had carried out a premises security risk assessment which was incorporated into its health and safety risk assessment.

Whilst we found no breaches of regulations, the provider should:

• Ensure all staff complete a suitable course of fire safety training.
• Amend the action plan detailing any issues identified in the health and safety risk assessment and infection prevention and control audit to show completion dates as a record of rectification of any issues found.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

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:

• 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.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cedar Practice on 11 February 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for older people, people with long term-conditions, families, children and young people, the working age (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• 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.
• Patients said 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 proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Action the provider SHOULD take to improve:

• Ensure Disclosure and Barring Service (DBS) checks are undertaken for staff who undertake chaperone duties at the practice.
• Ensure staff are made aware of what to do if the fridge temperature is out of range.
• Ensure that nursing staff receive Level three training in child safeguarding.
• Implement monitoring systems to evidence staff have read and understood governance policies.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with two GPs, which included one of the practice's GP partners who was also the registered manager, a health care assistant, the practice manager, two members of the reception staff, as well as one visiting professional who was working from the practice on the day of our visit. We also spoke with six people who used the service.

People using the service told us their GP listened to their concerns and explained the treatment options available. Most people felt that their privacy, dignity and independence were respected. The practice ensured that people's cultural needs were being met, this included the provision of an interpreting service when needed.

People we spoke with told us about their experience at the practice. Most of the people we spoke with were happy with the service they received from the practice. People told us that the clinical staff took time to discuss and explain their care and treatment. One person told us, "the doctors are very kind. They talk in plain English and explain everything."

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Staff received appropriate professional development. Patients told us they had confidence in the knowledge and skills of the GPs, the practice nurse and the other staff at the practice.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.