During an assessment under our new approach
Date of Assessment: 19 August to 21 August 2025.
Gudge Heath Lane Surgery is a GP practice and delivers services to approximately 9,500 patients under a contract held with NHS England. The National General Practice Profiles states demographics of people using the service are in line with local and national averages. Information published by Office for Health Improvement and Disparities shows that deprivation within the service population group is in the 9th decile (9 of 10). The lower the decile, the more deprived the service population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
During this inspection, we found there were effective safeguarding procedures in place to protect people from abuse and suitable arrangements to investigate incidents including outcomes shared with staff to mitigate risk and minimise reoccurrence. People received co-ordinated and joined up care, particularly when transitioning between services. People were given support to overcome health inequalities to ensure equal experience and outcomes. Leaders understood the challenges of meeting people’s needs and responded flexibility to ensure people could access care and treatment in a timely manner.
However, the service did not have fully effective and embedded processes to mitigate health and safety risks. This included effective control measures to reduce the risks related to legionella bacteria and the retention of Control of Substances Hazardous to Health (COSSH) risk assessments. We also identified there was a lack of regular, documented clinical supervision instigated by a supervisor in line with servicepolicy and national evidence-based prescribing guidelines to ensure staff were supported to carry out their roles. Although the service had oversight of risks, systems and processes were not always effective to address shortfalls in performance. We found the service did not always have fully effective and embedded processes for monitoring people’s health in relation to some high-risk medicines, long-term conditions and safety alerts. We identified 2 breaches of the legal regulations in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this inspection.