Gudge Heath Lane Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as Good. At this assessment, the rating has changed to Requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment. The service had not done all that was reasonably practicable to mitigate risks to the health and safety of people. This included shortfalls in relation to effective control measures to reduce the risks related to legionella bacteria. The service had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment in relation to their medicines or long-term conditions.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good service.

Staff were encouraged to raise concerns when things went wrong. They told us that significant events, complaints and examples of feedback were shared and discussed during regular staff meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in monthly governance meetings and minutes made available to staff who were unable to attend. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes that improved care for people.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service was supported by two care co-ordinators with the local primary care network (PCN) who were effective in bringing together multidisciplinary teams to support people with complex health and care needs such as arranging appropriate support and connecting people with service through service referrals. There were systems in place for processing information relating to newly registered people. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The service had a system in place for processing new information and summarisation of notes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were designated safeguarding children and adult leads at the service. There were quarterly multi-disciplinary meetings where safeguarding issues were discussed and these were attended by clinical and management staff. External stakeholders were invited to safeguarding meetings where relevant, such as community mental health teams. Systems were in place to appropriately refer people to the local authorities and information was shared amongst community teams where required. Safeguarding and chaperoning policies were in place and accessible to staff.

A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. Those staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

We reviewed a sample of people’s records as part of our remote clinical searches and saw care records noted how people were to be supported to remain safe. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating person and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened.

The service had a dedicated workflow team comprised of administrative staff which supported correspondence and communications. Staff told us urgent tasks were raised to GPs based on information escalated by Out of Hours and NHS 111 services, particularly, for people who were required to be seen in-hours by the service based on their symptoms and clinical presentation.

Leaders demonstrated the arrangements for reviewing abnormal results were prioritised to ensure people were followed up in a timely way. For example, we observed the service’s pathology clinical system mailbox and identified abnormal results were assigned either to the requesting clinician or to the duty GP for review on the day and correspondence was picked up via a ‘buddy system’ to prevent delays to care and treatment. Staff were able to describe their roles and responsibilities to manage risks associated with workflow and correspondence for people’s records.

The service did not always detect and control potential risks in the care environment. The service had carried out a fire risk assessment in February 2023 and were still in the process of completing the identified remedial actions. For example, we noted an electrical wiring testing inspection had not been carried out under national compliance standards of every 5 years, and had last been completed in 2017. After the inspection, the service provided evidence to demonstrate an updated fire risk assessment, electrical wiring testing inspection and emergency lighting servicing had been scheduled and booked for September 2025.

Although fire safety measures were in place such as fire alarm testing; fire extinguisher servicing and gas safety checks and schedules were not included in the fire safety policy in line with the Fire Safety Act 2021. However, after the inspection, the service provided us with evidence the fire policy had been updated to reflect all relevant safety procedures and schedules.

The service had not retained and stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all cleaning products stocked, alongside Safety Data Sheets (SDS) which the service had retained. This posed a health and safety risk for staff without guidance of usage and what to do in the case of incidents, in particular, to evaluate the specific risks associated with how that substance is used in the workplace.

Staff we spoke with stated the service ensured staff were supported in their roles, supervision and development was in place through appraisals. However, this was not documented and retained for audit trail purposes.

Staff could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. We noted there were daily slots available for clinicians to seek support with the on-the-day duty GP. The service had named supervisors for the medical students at the service under their education placements. However, the service had not ensured non-medical prescribing staff had access to ongoing supervision through a named supervisor, with regular audits to assess and review cases as outlined within the service’s clinical supervision policy. This meant there was a risk of medicines being prescribed outside the clinician’s scope of service and not in line with national guidelines.

However, staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals. There were systems in place to monitor staff training compliance and we noted all staff had completed mandatory training in line with service policy.

All recruitment and Human Resource (HR) records were kept in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 3 members of staff and information was available and up to date in line with service policy.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe service was mitigated and prevented lone working.

The service did not always assess or manage the risk of infection effectively.

There was a legionella risk assessment that had taken place in February 2025, however, not all actions had been taken as advised such as flexible hose and the removal of dead leg on the water tank. The service had a monthly water temperature sampling regime in place. However, the records did not document tested water temperatures in each room to demonstrate water temperatures were controlled to prevent the growth of Legionella bacteria. To comply with the Health Safety at Work Act 1974, hot water should be stored at 60 degrees Celsius or above, distributed at 50 degrees Celsius or above, and cold water below 20 degrees Celsius. The service did not have a legionella or safe water policy to document how the service was managing and mitigating the risks relating to legionella which was also advised within the risk assessment. After the on-site visit, the service provided evidence of a newly implemented legionella water safe policy which contained national guidance and updated service procedures.

However, the service had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. Risk assessments and audits were completed in relation to cleaning records and hand hygiene. Staff were aware of IPC procedures in place and were trained in line with service policy. Clinical waste arrangements were effective to ensure safe storage and appropriate labelling in line with infection prevention and control national guidelines.

The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences.

During our remote clinical searches, we identified not all people, who had been prescribed certain high-risk medicines, had been appropriately monitored and reviewed in line with national guidelines. For example, we noted 162 people out of a total of 292 who were prescribed a Direct-Acting Oral Anticoagulant (DOAC) had not had the required monitoring. This included a full-blood count (FBC) and a liver function test (LFT) blood monitoring as well as the calculation of creatine clearances (CrCL). We reviewed the clinical records of 5 of those people and identified 4 of them had not had their creatinine clearance calculated within 18 months, and 2 of the 5 had not had creatinine clearance calculated at all. This calculation is recommended as kidney function blood monitoring alone can overestimate renal function and increase risk of bleeding events.

We noted a further 33 people (which was approximately 9% of the total number of people with a recorded diagnosis of hypothyroidism) had also not had the required thyroid stimulating hormone (TSH) blood monitoring in the last 18 months despite recent prescriptions being issued. We noted the service had undertaken recalls for all 5 of people’s clinical records we reviewed, however, these had been carried out in the preceding 2 weeks. There was a lack of evidence of other proactive measures to encourage uptake of blood monitoring despite recent prescriptions for the records of people we reviewed.

During our clinical searches, we found people who were being prescribed combinations of medicines subject to medicine safety alerts were not always contacted to inform them on the risks of those combinations. For example, 16 people were identified to be prescribed a combination of clopidogrel (an antiplatelet medicine to prevent blood clots) omeprazole (used to treat heartburn, stomach ulcers and reflux disease). The clopidogrel and omeprazole safety alert recommends against their combined use because omeprazole can reduce the effectiveness of clopidogrel preventing blood clots. A review of the clinical records of 5 of those 16 people identified all 5 had not been advised about the risks set out in the safety alert. We noted 1 person had received a recent medicine review, but it was not clear from the clinical notes if the risks were discussed. All 5 people were noted to have had recent prescriptions issued in July 2025 but had not been invited to discuss the safety alert. Records had also not contained confirmation that appropriate monitoring had been reviewed to ensure safe prescribing. Following the review of these clinical records, the service had ensured people who were identified by the safety alert were contacted. Senior leaders told us the service would review the process to monitor the actions taken for people identified by safety alerts.

However, medicines were stored securely and the service held appropriate emergency equipment and emergency medicines. The service maintained appropriate fridge temperature records where vaccines were being stored and had taken appropriate action when fridge temperatures were outside of safe ranges.

Patient Group Directions (PGD) and Patient Specific Directions (PSD) were in place which relevant staff worked to when administering immunisations. Prescription stationery was logged and stored securely.