Sandy Lane Surgery

We carried out an announced inspection at Sandy Lane Surgery on 4 May 2022. Overall, the practice is rated as Requires improvement. We rated the key questions:

Safe - Requires improvement

Effective – Requires improvement

Caring – Good

Responsive – Requires improvement

Well-led – Requires improvement

Why we carried out this inspection

This comprehensive inspection was carried out following changes to registration and intelligence we hold about the quality of the service.

The full reports for previous inspections carried out under the former registered provider can be found by selecting the ‘all reports’ link for Sandy Lane Surgery on our website at www.cqc.org.uk

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Reviewing staff feedback forms
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A site visit

Our findings

• 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 rated the practice as requires improvement for providing safe care and treatment because:

• Not all staff had completed safeguarding training or to the required level in accordance with their role.
• Not all staff had completed training in safe working practices.
• Recruitment checks were not carried out in accordance with regulations.
• The systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients and others were not effective.
• Not all patients prescribed high risk medicines had received the required blood test monitoring in line with best practice guidance and number of patients were overdue a medicine review.
• There were missed opportunities to raise and analyse significant events.
• The system to review and act on patient safety alerts was not always effective.
• Evidence that staff vaccination and immunity for potential health care acquired infections was not recorded or risk assessed for all staff.

We rated the practice as requires improvement for providing an effective service because:

• There were patients with a potential missed diagnosis of diabetes.
• Patients with conditions including hypothyroidism had not always received the required monitoring.
• Further oversight was required for staff working in advanced roles.
• Not all staff had completed essential training.
• Medication reviews lacked structure, had not always been completed within the recommended timescale and failed to identify some patients who were overdue their monitoring.

We rated the practice as good for providing a caring service because:

• Staff treated patients with kindness, respect and compassion.
• The practice averages were in line or above local and national averages for providing caring services in the National GP patient survey.

We rated the practice as requires improvement for providing a responsive service because:

• The National GP Patient Survey 2021 results for the practice were lower than local and national averages in two of the four indicators in respect of providing responsive services.
• Some staff considered there were not enough staff employed to maintain a manageable workload or meet patient demand.
• Complaints identified the practice had not always been responsive to the needs of all patients and not always handled in line with the complaints policy.

We rated the practice as requires improvement for providing a well-led service because:

• Governance structures, processes and systems were being developed but not fully embedded into practice or effective.
• The provider had not gained assurances that all health and safety checks for the premise had been completed by the landlord to mitigate risks to patients and staff.
• Policies to support the governance and safe running of the practice were not always followed.
• Most staff felt supported in their work, reported a good work ethic and found line managers approachable but not always the GP partners.
• Statutory notifications had not been sent in a timely manner to the Care Quality Commission as required under The Care Quality Commission (Registration) Regulations 2009.
• The practice did not always have effective systems to identify, manage and mitigate risk.
• Not all staff had completed training in safe working practices to ensure their safety and well-being.

We found two 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.

In addition, the provider should:

• Improve the clinical record alert systems of people living in the same household of patients on the child protection register.
• Review the actions identified in the fire risk assessment to ensure these are all dated and signed once completed.
• Continue to improve the uptake of cervical cancer screening.
• Run searches on historic patient safety alerts to ensure continued compliance.
• Improve medicine reviews so they are structured and clearly identify any outstanding monitoring requirements.
• Develop a quality improvement programme with a formalised improvement plan.
• Continue to explore ways of improving patient experience with getting through to the practice by phone.
• Inform patients of their right to take their complaint to the Parliamentary and Health Service Ombudsman if they were unsatisfied with the practice’s response, as detailed in the practice’s complaints policy.

Shortly following the inspection, the provider sent us information detailing the immediate action they had taken in addressing a number of the identified shortfalls relating to medicines management, patient reviews, health and safety and staff training.

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