Church 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

We looked for evidence that people were protected from abuse and avoidable harm. We found that the practice had a good learning culture, staff could raise concerns, and managers investigated incidents thoroughly. However, we found some gaps in systems and processes around medicines management, safeguarding, safe environments, safe and effective staffing, and infection prevention and control which could potentially impact on patient safety.

At our previous inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice demonstrated a proactive and positive culture of safety, based on openness and honesty. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly. Staff were able to explain the process of how they would report an incident, or who they would seek guidance from to do so. Staff told us they were encouraged to report incidents and felt confident to do this. The practice had systems and processes in place, underpinned by policies, to formally manage incidents and complaints. During this assessment we reviewed a selection of incidents and complaints and saw appropriate action had been taken as well as learning shared through meetings.

The practice had formal systems and processes in place to manage referrals, clinical correspondence, pathology results and medical record summarising.

We observed that urgent 2-week wait cancer referrals were dealt with appropriately, there was a system was in place to ensure they were sent in a timely manner and that patients had attended for their appointment. We saw incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications, which was undertaken by the pharmacy team. Pathology results were actioned by clinicians and there was a ‘buddy’ system in place for when staff were absent. Clinical records of new patients were mostly received by electronic transfer and those that were received in paper form were summarised in the practice’s clinical record system. We saw that the practice had summarised 94% of patient records. At the time of the assessment, the practice had not completed a recent formal audit of the summarising process but advised us that they would add this to their audit schedule to ensure medical records were summarised in line with their policy.

The practice had a backlog of tasks within their clinical system, a significant proportion of which were automated and generated by the system as an audit trail when accessing clinical records and posed no patient risk. The practice was aware that this could impact on the clinical system’s performance and provided an action plan after the assessment of how they proposed to address this backlog and manage automated tasks going forward.

The practice had a clinical safeguarding children and adults lead and deputy in place, supported by a nominated administration lead. Staff knew who the leads were, how to escalate safeguarding concerns and were able to give examples of what would constitute a safeguarding concern.

At the time of our assessment, safeguarding policies contained some out-of-date guidance and links. After the assessment, the practice reviewed their policies and sent an updated combined safeguarding children and adults policy and handbook.

We saw that safeguarding children and adults training formed part of the practice’s mandatory training schedule, including preventing radicalisation. However, not all non-clinical staff had undertaken training to a level appropriate to their role. During the assessment, the practice facilitated staff to complete the appropriate training. After the assessment, the practice sent evidence that clinical staff had completed level 3 children and adults training, non-clinical staff level 2, and all staff had completed preventing radicalisation training.

The practice had systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations.

As part of our assessment, we reviewed 3 safeguarding records and found some gaps in the coding and linking of family/household members. After the assessment, the practice confirmed that they would undertake an immediate review of their safeguarding registers to ensure household-level coding and appropriate alerts were in place on clinical records.

The safeguarding leads attended external safeguarding meetings and held regular multidisciplinary meetings where safeguarding was discussed and documented.

Staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check. At our on-site assessment we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

Staff were confident in the systems and processes to respond to medical emergencies. Non-clinical staff demonstrated they were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient. The practice had provided sepsis awareness training for clinical and non-clinical staff both face-to-face and through an on-line module.

At our on-site visit, we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. The practice had undertaken a review of the emergency medicines available at the practice based on local context and the services they provided, and a risk assessment had been undertaken to support these decisions. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place which were recorded. Records confirmed that all staff had completed basic life support annually via face-to-face training and consolidated through on-line training.

Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their computer desktop.

The practice was located in a purpose-built, 2-storey, medical facility. Patient services were delivered from the ground floor. During the assessment, we found appropriate maintenance contracts in place for gas, electricity, portable appliance testing (PAT), medical calibration, fire alarm panel, fire extinguishers, emergency lighting, intruder alarm and the closed-circuit television (CCTV).

The practice had undertaken their own risk assessments for fire, Legionella, Control of Substances Hazardous to Health (COSHH) and health and safety. Previous risk assessments undertaken by external contractors for fire and legionella were not available for review. Weekly water temperature testing was undertaken and logged. We discussed with the practice that there were no requirements about who carried out premises risk assessments other than they should be assured that the nominated person had sufficient knowledge, training and experience. After the assessment, the practice confirmed that they had engaged an external contractor to undertake a Legionella risk assessment in November 2025.

There was a fire policy in place and fire evacuation instructions in each room. Weekly fire alarm testing was undertaken and recorded. A fire evacuation, which included staff only, was undertaken in September 2025, and had been recorded in meeting minutes. There was no documentation of any previous fire evacuations and some staff indicated they had not been part of a fire evacuation drill during their time at the practice. There was a named and trained fire marshal but there was no formally identified deputy in place. After the assessment the practice sent an updated fire policy which outlined the nomination and training of additional staff in the role of fire marshal.

Fire awareness training formed part of the practice’s mandatory training schedule, but not all staff had undertaken the training or completed it within a frequency in line with guidance. During the assessment, staff completed this training and the practice told us this would be updated annually.

The practice’s accident book did not conform to current Health and Safety Executive requirements.

As part of our on-site assessment, we reviewed 3 clinical staff recruitment files and found employment documentation in accordance with regulations were in place. For example, photographic identification, signed contracts, references and Disclosure and Barring Service (DBS). Professional registration checks were undertaken at the point of recruitment, but there was no system in place to check these on an ongoing basis. During the assessment the practice confirmed that they planned to check these annually and maintain a record.

We saw there was a structured approach to induction and staff we spoke with told us their induction was tailored to their roles and included a period of shadowing with colleagues.

The practice had identified mandatory training for clinical and non-clinical staff. We found some training was not on a level and frequency in line with guidance and there were some gaps in up-to-date training. During the assessment, staff completed the required training, and the practice updated policies to ensure training was undertaken in line with best practice and guidance. Role-specific training for the nursing team was overseen by the lead nurse who undertook their annual appraisals. The management team did not have oversight of this but told us they would implement a role-specific training matrix to enable them to monitor this.

There was a process in place to ensure staff had regular appraisals. Clinical staff told us they had a clinical supervisor, debrief sessions and that there were regular clinical meetings where cases were reviewed. They told us they felt fully supported clinically from all GPs and that there was an approachable ‘open-door’ policy. The practice undertook reviews of consultations and prescribing of staff employed in advanced clinical practice.

The practice supported staff upskilling and development, which some staff told us they appreciated to progress in their career. We saw that some staff who had commenced at the practice as an apprentice were now employed by the practice and the practice had supported a nurse to become an independent prescriber.

The practice had a nominated infection prevention and control (IPC) lead and policies in place. Staff knew who the nominated IPC lead was and had received IPC training relevant to their role, which was updated annually.

We spoke with the nominated lead who told us they had dedicated time to undertake this role and had completed the practice’s mandatory on-line training. They had not undertaken any additional IPC training to support them in this extended role but knew how to contact the local IPC specialist team for further advice. The practice indicated that they planned to source additional training to support the IPC lead.

The practice had undertaken an IPC audit in August 2025 which had attained 100% compliance with no remedial actions identified. We discussed that non-compliant treatment room floors and clinical sinks were not included on the audit or action plan to enable them to monitor any future IPC refurbishments. The practice told us that they had planned to replace the treatment room floors and were currently seeking quotations.

The practice had a system in place to capture the immunisation status of staff at the point of recruitment through a self-declaration process. We reviewed 3 clinical staff files and saw that in 2 files the staff members had provided their full immunisation records. Evidence for a third staff member was provided after the assessment. We discussed with the practice if a self-declaration met the guidance requirements of satisfactory evidence of protection to enable them to ensure patients and staff were adequately protected. The practice told us they planned to review their processes.

Cleaning was undertaken by contract cleaners, who had access to appropriate colour-coded equipment and cleaning materials in a dedicated locked area. On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free.

The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including the management of sharps injuries, handwashing and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff.

As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. These searches included patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines which required patient monitoring, medicines subject to a patient safety alert, medicines usage and medicines reviews. Although there were systems and in place to recall and manage patients in line with guidance, we found some gaps in these processes and highlighted some patients for further review by the practice.

There were 51 patients prescribed the DMARD Methotrexate, of which 7 did not appear to have had monitoring in the last 6 months. We reviewed 5 patient records and found 4 of the patients were having monitoring and prescribing undertaken by secondary care. We noted that the day of the week on which this medicine should be taken had recently been added to some records in line with the September 2020 Medicines and Healthcare products Regulatory Agency (MHRA) alert. We highlighted a patient for further review, and the practice provided a comprehensive response in relation to their ongoing care and management.

There were 409 patients prescribed a direct oral anticoagulant (DOAC). We reviewed 5 patients from the category of patients over the age of 75 years who had not had monitoring in the last 6 months, of which there were 109. We found that for some patients the creatinine clearance level had been calculated using an out-of-date weight and blood result (the creatinine clearance test helps provide information about how well the kidneys are working). The practice was aware that further work was required in this area and discussed this during the assessment. Immediately after the assessment, the practice provided an action plan which formalised their planned approach to monitoring patients prescribed a DOAC. We highlighted a patient for further review, and the practice provided a comprehensive response in relation to their ongoing care and management.

We reviewed the prescribing of an aldosterone antagonist and an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), which are used to treat raised blood pressure, and had been subject to an MHRA alert. We found that 81 patients had been prescribed these combined medicines of which 9 had not received the required monitoring. The practice was aware that this was an area of improvement and had an action plan to address this.

There were 422 patients prescribed an oral non-steroidal anti-inflammatory drug (NSAID) over the age of 65 or an antiplatelet over the age of 75, of which 136 had not been prescribed a protein pump inhibitor (PPI) in line with guidance. We highlighted a patient for further review, and the practice provided a comprehensive response in relation to their ongoing care and management.

We reviewed a sample of medicines reviews for patients on polypharmacy (more than 10 medicines) where there had been no medication review in last 18 months. We found there were 701 patients prescribed 10 or more medicines, of which 137 had not had a medicines review in last 18 months. Our review found some medicine quantities were not aligned, the reviews did not always cover all medicines, monitoring was not always in date and some long-term condition reviews were overdue. After the assessment the practice provided an action plan of how they planned to address the management of polypharmacy.

At our on-site visit, we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions.

Blank prescription stationery was securely stored, and their use was monitored in line with national guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that prescribing outcomes were broadly in line with average outcomes. The practice engaged in prescribing initiatives and utilised medicines analytic software to ensure safe and effective prescribing.