Sidley Medical Practice Also known as Dr Lawton & Partners

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

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to inadequate. We identified breaches of the regulations.

The practice did not have established and effective systems in place to keep vulnerable children and adults safe. Medicines were not managed safely. Best practice guidance had not been followed for the prescribing and monitoring of medicines. Medicines safety alerts had not been acted on which placed people at risk of harm.

There was not sufficient staff with the right skills, qualifications and experience to provide care safely. Not all clinical staff had received an appraisal.

People were not encouraged or supported to raise concerns, and the service did not learn from events to improve the service. The facilities and equipment at the branch surgery located in Albert Road, Bexhill-On-Sea did not meet the needs of people. The provider had not identified or mitigated risks to service users or practice staff.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they did not feel supported by management and were not confident to raise concerns. They did not believe any concerns reported would be investigated, learning identified and practices improved. Staff told us information was not shared with them by the management team or partners to inform or improve safety and standards of care.

The provider failed to demonstrate a duty of candour, apologising to people and explaining what happened and why. For example, we reviewed the practice significant events records and found some incidents had not been thoroughly investigated, learning identified and outcomes shared with staff. People told us they had not received explanations as to why they had experienced delays in receiving care. The provider had not audited their systems to identify trends of incidents or occurrences.

During our inspection, we identified incidents which had put patients at risk of avoidable harm which had not been identified as a significant event or investigated to prevent reoccurrence. For example, failure to follow up appropriately with patients whose presented with deteriorating health.

Staff told us they did not feel supported by management and were not confident to raise concerns. They did not believe any concerns reported would be investigated, learning identified and practices improved. Staff told us information was not shared with them by the management team or partners to inform or improve safety and standards of care.

The provider failed to demonstrate a duty of candour, apologising to people and explaining what happened and why. For example, we reviewed the practice significant events records and found some incidents had not been thoroughly investigated, learning identified and outcomes shared with staff. People told us they had not received explanations as to why they had experienced delays in receiving care. The provider had not audited their systems to identify trends of incidents or occurrences.

During our inspection, we identified incidents which had put patients at risk of avoidable harm which had not been identified as a significant event or investigated to prevent reoccurrence. For example, failure to follow up appropriately with patients whose presented with deteriorating health.

There were not established and effective systems in place to keep people safe. Some clinicians had not had appropriate recruitment checks conducted prior to being appointed.

The practice did not maintain accurate records for children and adults identified as at risk of harm. We found clinical records lacked details of who had legal authority for children on the child protection register. Records were out of date and/or did not contain accurate contact names and addresses for people or details of the concern(s). Staff failed to actively monitor the most vulnerable children/people.

There were not effective policies in place to identify and respond to risks. There were no defined escalation procedures when vulnerable people failed to attend appointment(s) and/or did not engage with services. We reviewed the practice’s safeguarding meeting minutes and found that significant risks to an eight-week old child had not been addressed, no actions had been proposed and/or timescales stipulated for a response to ensure the safety of the child.

Risks identified by people were not consistently acted on. People were encouraged to attend monitoring appointments such as to have their blood pressure checked. However, we found where concerns had been identified the provider failed/or delayed the timely assessment of the person placing them at risk of harm.

There were not established and effective systems in place to ensure the safe and appropriate appointment of staff. We found the provider had not conducted appropriate checks for some clinicians prior to their appointment.

Staff told us appropriate staffing levels and skill mix were not maintained to make sure people received consistently safe, good quality care that met their needs. Staff told us clinics were not cancelled when staff were absent requiring other staff to add to already full clinical schedules.

We found documents, test results and prescriptions were not reviewed and acted on in a timely way. For example, we found 230 results (pathology, x-rays etc.) of which 138 were marked as urgent tests results awaiting review These results dated from 4 April 2025. We found 499 clinical tasks outstanding of which 210 were marked as urgent dating from 11 March 2025 and awaiting processing. There were 228 prescription enquiries outstanding with 21 urgent enquiries the latest dated 9 April 2025.

Staff told us they felt overwhelmed and unsupported. We found clinicians contacted patients outside of working hours to advise them of test results and complete triage pathways.

Staff had completed appropriate training for example in basic life support and safeguarding.

There were not established and effective systems in place to ensure the safe and appropriate appointment of staff. We found the provider had not conducted appropriate checks for some clinicians prior to their appointment.

Staff told us appropriate staffing levels and skill mix were not maintained to make sure people received consistently safe, good quality care that met their needs. Staff told us clinics were not cancelled when staff were absent requiring other staff to add to already full clinical schedules.

We found documents, test results and prescriptions were not reviewed and acted on in a timely way. For example, we found 230 results (pathology, x-rays etc.) of which 138 were marked as urgent tests results awaiting review These results dated from 4 April 2025. We found 499 clinical tasks outstanding of which 210 were marked as urgent dating from 11 March 2025 and awaiting processing. There were 228 prescription enquiries outstanding with 21 urgent enquiries the latest dated 9 April 2025.

Staff told us they felt overwhelmed and unsupported. We found clinicians contacted patients outside of working hours to advise them of test results and complete triage pathways.

Staff had completed appropriate training for example in basic life support and safeguarding.

The provider had not confirmed the immunisation status of all clinical staff to mitigate the risk to them and others of infection.

Staff reported poor hand hygiene by some clinicians and failure to adhere to best practice guidance ensuring internal examinations are conducted by staff who were bare below the elbows.

The branch surgery at Albert Road was in poor state of repair presenting infection prevention control risks. We found cracked and peeling plaster and paint on the walls. There were fractured glass windows in the staff room and communal hallway, broken tiles behind the sinks with one completely loose preventing effective cleaning. No action had been taken to mitigate this risk. Staff told us they had not been trained and did not feel confident using the biohazard spillage kit.

The main surgery was found to be clean and tidy in appearance.

There were not established and effective systems in place for the safe management of medicines. We found patient recall systems were not in place to ensure safe monitoring of medicines. Some people had not been informed of risks relating to the use of their medicines. Some people had not had appropriate medication reviews conducted to ensure safe prescribing.

We found guidance encouraging best practice by the National Institute for Health and Care Excellence had not been followed by some staff. Medicines and Healthcare products Regulatory Agency alerts (providing alerts, recalls and safety information on drugs and medical devices) had not been appropriately actioned placing people at risk of harm. For example, we identified 116 patients who may have not had the required monitoring prior to being prescribed the medicine. Our sample group of five records showed none of the patients had been informed of the potential risk related to taking the medication. The clinician(s) had not ensured they had been appropriately monitored to ensure safe prescribing of the medication. Thereby mitigating the risk of adverse biochemical events. All five of the patients had been placed at risk of harm.

We found delays occurred in the review, authorising and processing of people’s prescriptions.

Staff told us clinical meetings were not held to discuss guidance, staff experiences and promote best practice. The provider did not conduct checks on individuals or collective prescribing behaviours to ensure adherence to safe practice.