Sandy Lane Surgery

Updated 8 September 2023

Sandy Lane Surgery is located in Rugeley at:

Sandy Lane Surgery

Rugeley

Staffordshire

WS15 2LB

Horsefair Practice Group (HFPG) acquired Sandy Lane Surgery in April 2019. The practice is located in a purpose-built health centre which has been open since January 2007. The provider is a partnership registered with CQC to deliver the regulated activities: diagnostic and screening procedures, treatment of disease, disorder or injury, family planning, maternity and midwifery services and surgical procedures from this location only.

The practice is situated within the NHS Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) and delivers Alternative Provider Medical Services (APMS) to a patient population of 9,503, a decrease of 500 patients since the last inspection. This is part of a contract held with NHS England. The practice is part of the Rugeley and Great Haywood Primary Care Network (PCN), a wider network of GP practices that work collaboratively to deliver primary care services.

Information published by Public Health England shows that deprivation within the practice population group is in the sixth lowest decile (six out of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is, 98% White, 0.9% Asian, 0.8% Mixed.

The practice is a training practice for GP registrars to gain experience and higher qualifications in general practice and family medicine.

The practice staffing comprises:

• Two GP partners
• Three salaried GPs
• Three long-term locum GPs
• One nurse manager, 1 nurse practitioner, 3 practice nurses, 1 nursing associate and 1 phlebotomist
• A practice manager, a management assistant, data quality manager and a team of administrative and reception staff
• A range of staff employed by the PCN including 1 urgent care practitioner, 4 pharmacists, a first contact physio, a mental health practitioner and a social prescriber

The practice is open between 8am and 6.30pm Monday to Friday. Out of hours services are provided via NHS 111. Further information about the practice is available via their website at: www.sandylanesurgery.org.uk

Updated 8 September 2023

We carried out an announced comprehensive inspection at Sandy Lane Surgery on 17 July 2023. Overall, the practice is rated as requires improvement. We rated the key questions:

Safe - requires improvement

Effective - good

Caring - good

Responsive - requires improvement

Well-led - good

Following our previous inspection on 4 May 2022 the practice was rated requires improvement overall and for all key questions except for caring, which was rated as good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Sandy Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

Our focus included:

• Safe, effective, caring, responsive and well led key questions.
• A follow up of breaches of regulation and ‘shoulds’ identified in previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.
• Feedback from external stakeholders.
• Conducting an interview with a representative of the patient participation group (PPG) using video conferencing.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

Although many improvements had been made in a number of areas, we identified ongoing concerns in relation to people receiving safe and responsive care.

We rated the provider as requires improvement for providing safe services because:

• Recruitment checks although improved had not been carried out fully in accordance with regulations.
• Appropriate standards of cleanliness and hygiene were not always maintained.
• Three of the 6 prescribing indicators for the practice were tending towards a negative variation compared with local and national averages.
• Medication reviews were not always adequately structured or managed in a way to protect patients.
• Checks on controlled drugs held on the premises had not been carried out in accordance with the practice policy.
• Vaccine fridge temperatures were not being observed and recorded daily during the working week.
• Some significant event records lacked detail of the risks, and the learning outcomes were not always noted on the paper records held.

We rated the provider as requires improvement for providing responsive services because:

• The National GP Patient Survey 2023 results for the practice showed patient satisfaction continued to be significantly lower than local and national averages in respect of accessing a responsive service.

• People had not always been able to access care and treatment in a timely way.

We found that:

• Staff had completed essential training and were provided with opportunities for learning and development..
• Systems for monitoring the safe prescribing of medicines requiring regular monitoring had improved.
• Improvements in relation to the oversight and management of patient safety alerts, complaints and significant events had been implemented.
• The systems and processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients had improved. However, some hazards had not been assessed.
• Arrangements were in place to review the prescribing practices of non-clinical prescribers.
• Staff dealt with patients with kindness and respect.
• The practice had increased its patients registered as carers.
• Structures, processes, and systems to support good governance were becoming embedded into practice. Staff felt supported in their work and found leaders approachable and visible.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

• Take action to ensure patients prescribed a medicine for the treatment of rheumatoid arthritis are instructed to only take their medicine once a week and on the same day each week.
• Take steps to ensure where shared care agreements are in place they are easily accessible and blood test results completed in secondary care are recorded in the patient record.
• Take action to improve the quality of medicine reviews.
• Take steps to improve cervical screening and child immunisation uptake.
• Take action to ensure recruitment procedures are operated effectively to ensure only fit and proper persons are employed.
• Take action to improve patient experience of receiving a responsive service.
• Take steps to ensure clinicians work in line with current evidence-based practice. For example, patients presenting with an acute exacerbation of asthma.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care