Church Lane Medical Centre

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

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed health and safety risks. The service worked with people and healthcare partners to establish and maintain safe systems of care. However, certain processes for managing and monitoring urgent referrals, test results and internal tasks requiring action were identified as needing review. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff mostly managed medicines well although there were some areas that required review with regard to monitoring of patients on high-risk medicines, medicine reviews and emergency equipment.

This service scored 69 (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 practice. Managers encouraged staff to raise concerns when things went wrong. During clinical meetings, staff discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. For example, the procedure for notifying secretaries an urgent referral was required was revised to route requests to the shared secretaries’ group task list, rather than to individual secretaries. This change was implemented to support timely completion of urgent referrals in line with recommended guidelines.

The service worked with people and healthcare partners to establish and maintain safe systems of care. However, certain processes for managing and monitoring test results, urgent referrals and internal tasks requiring action were identified as needing review. During the assessment on 21 October, we noted 12 urgent pathology results in the doctors’ inbox from 16 October awaiting review. Additionally, there were 557 outstanding tasks on the receptionists’ task list, dating back to 5 September 2025, related to booking appointments or arranging repeat tests. It was unclear whether appropriate action had been taken. The process for monitoring whether urgent referrals to secondary care had been booked within the recommended timeframe had not been followed. For example, a referral made on 6 October 2025 remained on the referral summary screen without a scheduled appointment known.

During the assessment, the pathology results were actioned, and the urgent referral was followed up to ensure an appointment had been booked. Immediately following the site visit, the provider updated staff on the revised process for managing urgent referrals and implemented a system to address and monitor outstanding tasks going forward.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

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. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on actions to take if their condition deteriorated. Emergency equipment was available although monitoring checks were completed monthly and not weekly as per recommended guidance.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service did not consistently ensure that medicines and treatments were safe or tailored to individuals’ needs, capacities, and preferences. Although staff engaged patients in medicine reviews and supported them in understanding how to manage their medicines safely, it was unclear, based on clinician discussions and record reviews, whether a standardised template was consistently used to document these reviews. Following the assessment, the provider submitted evidence confirming a standardised medicine review template had been implemented and discussed with staff to support consistent documentation.

Staff followed established protocols to promote safe prescribing practices. However, our review of clinical records identified several patients who were overdue for medicine reviews, with system-generated prompts not actioned. For example, two patients were prescribed medicines that are generally discouraged in combination unless clinically justified, and we could not see evidence the prescribing alert prompts had been acknowledged. Additionally, some patients prescribed high-risk medicines requiring regular monitoring had not received the recommended tests within the appropriate timeframe, as outlined in clinical guidance. For instance, of the 428 patients prescribed a Gabapentoid medicine (medicines used to primarily treat neuropathic pain, epilepsy and anxiety), 163 had not received monitoring in the previous 12 months. We reviewed two of these records and found that neither had undergone a medicine review within the previous 12 months.

Medicines were stored securely and at appropriate temperatures. Staff routinely checked stock levels and expiry dates for all medicines, including vaccines and emergency medicines. However, these checks were conducted monthly rather than weekly, which does not align with Resuscitation Council UK guidelines. Furthermore, the contents of the emergency trolley did not match the checklist. Immediately following the site visit, the provider completed a risk assessment and reviewed their emergency medicines and checking processes to ensure compliance with recommended standards.

Staff followed procedures to ensure that individuals prescribed medicines with specific risks received appropriate monitoring, although we observed that some patients were not seen within the recommended timeframe, and there was no system in place to alert the GP if a patient failed to attend for monitoring within the specified timeframe. Following the assessment, the practice provided evidence of a reviewed recall system and the establishment of a dedicated recall working group, overseen by a GP, to manage and monitor medicine monitoring recalls effectively.

Medicines were prescribed appropriately to support positive care outcomes, including antibiotics. However, prescribing data reviewed during the assessment indicated that the practice had high prescribing rates for broad-spectrum antibiotics and Gabapentinoids. While the provider was aware of this data, there was no plan in place to address it at the time of the assessment.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls.