Sandy Lane Surgery

We carried out an announced inspection at Sandy Lane Surgery on 6 & 8 April 2022. Overall, the practice is rated as good. We inspected;

Safe -Good

Effective -Good

Caring – Good

Responsive – Requires Improvement

Well-led -Good

The previous provider of this service was inspected on 1 November 2016 and was rated good overall and for all key questions, except for well-led, which was rated outstanding. A new provider was registered in October 2020 and the previous report and provider profile was archived in November 2020.

Why we carried out this inspection

This inspection was a fully comprehensive inspection to give a rating to the new provider of the service.

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Lancashire and South Cumbria. To understand the experience of GP Providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

How we carried out the inspection

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 included:

• Conducting staff interviews using video conferencing and face to face
• 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 and reviewing evidence from the provider
• A 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 Good overall

We found that:

• The practice demonstrated that systems and processes were in place to protect patients and staff from harm in all areas of service delivery. There were areas that the practice acknowledged would benefit from strengthening and they took action immediately to address these areas.
• Effective staffing arrangements were in place and patients with long-term conditions and all other clinical areas received care and treatment in line with best practice.
• Patient feedback in relation to being treated with kindness, respect and dignity, as well as being involved in their care and treatment was in line with local and national averages. In addition, the practice had proactively surveyed their patients as a result of feedback to seek out areas for improvement.
• Feedback was variable in relation to access to care and treatment however; the practice had surveyed patients to seek out areas to improve and were engaging with patients about the new ways of working in primary care. Actions to improve patient satisfaction around access to the service had not yet been implemented.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic and continued to follow government guidance to mitigate the risk of this virus.
• Governance arrangements were in place and working to facilitate the services offered to the practice population. They demonstrated that these systems and processes were embedded and able to adapt to challenges; supporting the practice to be responsive to quality improvement activity and provide an environment for the beginnings of innovation.

Whilst we found no breaches of regulations, the provider should:

• Establish a formal system of oversight for all allied health professionals working in the practice including non-medical prescribers.
• Complete actions for all risk assessments or audits in relation to environmental risks, including infection prevention and control.
• Bring cervical uptake to expected targets.
• Take action to improve patient satisfaction with access to care and treatment.

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