The Cedars Surgery

Updated 24 October 2023

The Cedars Surgery is located at 24 Marine Road, Walmer, Deal, Kent, CT14 7DN.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Kent and Medway Integrated Care System (ICS) General Medical Services (GMS) to a patient population of approximately 10,000 patients. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices in East Kent: Deal and Sandwich Primary Care Network (PCN).

Information published by Public Health England shows that deprivation score within the practice population group is 7 (7 out of 10). The lower the score, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 98% White, 0.9% Asian, 0.2% Black, 0.8% Mixed and 0.1% Other.

The number of patients under the age of 18 and aged 18 to 64 closely mirrors the local and national averages. The practice has a higher than average proportion number of patients over the age of 65.

The practice consists of 6 partner GPs, 4 practice nurses, 1 advanced care practitioner, and 3 health care assistants. The practice is supported by a team of reception and administration staff. The practice manager and deputy practice manager provide managerial oversight. The provider also employs a locum allied care professional when required.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the PCN, where late evening and weekend appointments are available; appointments are booked via the practice. Out of hours services are provided by NHS 111. NHS 111 deals with urgent problems when GP surgeries are closed.

Updated 24 October 2023

We carried out an announced focused inspection at The Cedars Surgery. We conducted remote clinical searches on the practice’s computer system on 5 September 2023 and conducted an onsite inspection of the practice on 6 September 2023.

Following our previous inspection on 9 June 2022, the practice was rated as requires improvement overall as well as for providing safe and effective services, and good for providing responsive and well-led services. After our inspection in June 2022, the provider wrote to us with an action plan outlining how they would make the necessary improvements to comply with regulations.

The full report for the June 2022 inspection can be found by selecting the ‘all reports’ link for The Cedars Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection on 6 September 2023 to follow up the breaches of regulation found in our previous inspection in June 2022. Overall, the practice remains rated as Requires Improvement.

The key questions at this inspection are rated as:

Safe - Requires Improvement

Effective - Requires Improvement

Responsive – Requires Improvement

Well-led – Requires Improvement

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from the previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.

Our findings

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 have rated this practice as Requires Improvement overall

We found that:

• The practice had systems and processes to keep people safe and safeguarded from abuse.
• Appropriate standards of cleanliness and hygiene were met.
• The practice learned and made improvements when things went wrong.
• The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
• The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Complaints were listened and responded to and used to improve the quality of care.
• There was compassionate, inclusive and effective leadership at all levels.
• There were systems and processes for learning, continuous improvement and innovation.
• The practice organised and delivered services to meet patients’ needs.
• Patients could not always access care and treatment in a timely way. We saw the practice was attempting to improve access.

We rated the practice as Requires Improvement for providing safe, effective, responsive and well-led services because:

• Our clinical record searches found improvement was still required in relation to the safe management and monitoring of some long-term conditions, high-risk medicines and medicine safety alerts.
• Improvements in processes for managing risks, issues and performance were still required.
• Improvements were required in relation to patient satisfaction with access to services. Whilst we recognise the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients, our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback.

We checked the areas where the provider should make improvements from our last inspection in June 2022 and found:

• The provider had a comprehensive programme of quality improvement activity.
• The provider had a system to monitor the outcome of plans to improve performance relating to the uptake of cervical cancer screening.
• New systems to monitor staff personnel files and staff training had been fully embedded.

At this inspection in September 2023, we found there continued to be breaches of regulations. The provider must:

• 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:

• Take steps to monitor and improve screening uptake, specifically, cervical cancer screening.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care