Cedarlea Practice Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was providing well led care in accordance with the relevant regulations and had taken into consideration appropriate guidance. The provider had made improvements in relation to the regulatory breach we found at our inspection on 27 February 2024.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

At the assessment on 10 July 2024, we found the practice had made the following improvements to comply with the regulation: An electrical installation condition report (fixed wiring) had been completed, no issues for action were identified. All items of medical emergency kit that were previously not available have been purchased and are available for use. New systems and checks including daily checks have been implemented to ensure availability and effectiveness of medical emergency equipment. Logs were kept demonstrating checks had been completed. Action has been taken action to implement all recommendations in the Legionella risk assessment. For example, water samples had been taken and certificates demonstrating compliance are available. Hot and cold water temperatures are being monitored and logged. The boiler has been serviced. Some staff have completed legionella training to ensure they are aware of their role and the procedures to follow. An external professional has completed a fire risk assessment and some of the issues identified in the risk assessment have been acted upon. For example, fire escape signage is now in place throughout the building, carbon monoxide detectors have been made available as required. Work has been completed to ensure external escape routes are clear of debris and moss removed from pathways. Some issues remain outstanding, and a plan is in place with dates for actions to be completed. We were assured that outstanding issues such as installation of a new fire alarm system, emergency lighting and fire doors would be completed within the following 9 months. Other systems to raise the alarm in case of fire are in place until this work has been completed. Fire safety checks have been implemented such as weekly checks of smoke alarms, fire extinguishers and emergency exit routes. Other fire safety equipment currently available at the practice is also subject to weekly checks. A new fire safety policy has been developed.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.