We carried out an announced comprehensive inspection at The Cedars Surgery on 20 February 2020 as part of our inspection programme.
We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection in July 2017.
This inspection focused on the following key questions:
- Are services effective?
- Are services responsive?
- Are services well led?
Because of the assurance received from our review of information, we carried forward the ratings for the following key questions:
- Are services safe? (Good)
- Are services caring? (Good)
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 provided the practice with Care Quality Commission feedback cards prior to the inspection and we received 19 completed cards. Patients were generally positive about the practice staff, their experiences, and the care and treatment they received.
We have rated this practice as good overall; good for providing effective, responsive and well led services; Requires Improvement for the population group which includes working age people (including those recently retired and students) and good for the remaining population groups because:
- Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
- The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment.
- Staff worked together and with other organisations to deliver effective care and treatment.
- There was compassionate, inclusive and effective leadership at all levels. This included working with and supporting the practice Patient Participation group (PPG).
- The practice had a clear vision and set of values that prioritised quality and sustainability.
- The practice had a culture that drove high quality sustainable care.
- There were clear responsibilities, roles and systems of accountability to support good governance and management.
- There were clear and effective processes for managing risks, issues and performance.
Although we did not find any beaches of regulation on this inspection, we did see one area where the provider should make improvements. This was to:
- Monitor arrangements for recording consent to include the administration of joint injections.
- Continue monitoring the uptake of cervical screening in line with national guidance.
- Continue monitoring the effectiveness and need for two week wait referrals.
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