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

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 practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• 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. The practice had reviewed their exception reporting data and made changes to improve, although it was too early for the verified data to be published. Child immunisation data showed the practice had not achieved the 90% national target for three of the four vaccines.
• Staff involved and treated patients with compassion, kindness, dignity and respect. However, patient satisfaction with GP care was below local and national averages for some aspects of care.
• The practice had reviewed the telephone system and were making changes to improve access to appointments.
• There was a governance structure and practice policies in place. However, the governance arrangements had not identified missing references from recruitment files or the need for a Disclosure and Barring Service risk assessment. They had also failed to review the complaints processes to include the health ombudsman and a verbal complaints log.

The areas where the provider must make improvements are:

• 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 processes for increasing compliance with the national childhood vaccination programme.
• Ensure practice oversight of performance related to exception reporting.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the 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:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• All staff had received safeguarding relevant to their role.
• 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 used innovative and proactive methods to improve patient outcomes. For example, identifying and using social prescribing services to support patients to live healthier lives.
• 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. 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 proactively 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.

The areas where the provider should make improvement are:

• Ensure failsafe systems are in place to ensure results were received for all samples sent for the cervical screening programme.
• Ensure patient outcomes are reviewed to ensure that patients with long term conditions receive appropriate care and treatment.
• Review of the system in place to promote the benefits of cervical screening in order to increase patient uptake.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During this inspection we spoke with eight patients, five members of staff and the practice manager.

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.