The Cedars Surgery

Updated 24 December 2018

The Cedars Surgery is located in purpose built premises near the town centre of Maidenhead. It holds a general medical services contract to provide GP services to approximately 10,778 patients. Services are provided by The Cedars Surgery and the lead GP is the registered manager. (A registered manager is a person registered with the CQC to manage the service. They have a legal responsibility to meet the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run). The Cedars Surgery is part of East Berkshire Clinical Commissioning Group and the local federation of GP practices for Windsor, Ascot and Maidenhead.

There are three GP partners (all female, whole time equivalent (WTE) 2.3 full time GPs), three salaried GPs (two female, one male, WTE 1.75) and two long term locum GPs (both female, WTE 1.24). The practice currently has two trainee GPs (one female, one male, WTE 1.6). The all-female nursing team consists of a Practice Nurse manager (WTE 0.85), an Advanced Nurse Practitioner (WTE 0.6), three Practice Nurses (WTE 1.84) a Women’s health practitioner (midwifery background, WTE 0.53) and a phlebotomist/health care assistant (WTE 0.59). The practice had recently recruited a Clinical Pharmacist to support the clinical team.

Day-to-day running of the practice was undertaken by a Practice Manager (WTE 1), an assistant practice manager (WTE 0.83) and a variety of reception, administration and secretarial staff. There was also an apprentice working alongside the administration team.

The practice is registered with CQC to provide the following regulated activities: Diagnostic and screening procedures, Family planning, Maternity and midwifery services, Surgical procedures and Treatment of disorder, disease and injury.

All services and regulated activities are provided from:

8 Cookham Road, Maidenhead, Berkshire, SL6 8AJ

Online services and practice information can be accessed from:

www.thecedarssurgery.co.uk

According to data from the Office for National Statistics this area of Berkshire has high levels of affluence and low levels of deprivation. However, there are pockets of high deprivation within the practice boundary which affects registered patients. The practice has a predominantly higher proportion of working age patients (aged between 25 and 40 years) compared to the national average. The ethnic mix of patients is predominantly white with approximately 19% of registered patients belonging to black and other minority ethnic groups.

Updated 24 December 2018

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

Updated 19 April 2018

Updated 19 April 2018

Updated 19 April 2018

Updated 19 April 2018

Updated 19 April 2018

Updated 19 April 2018