Sandy Lane Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 67 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was mainly positive. Most people felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Digital flags were used within the care records system to highlight any specific individual needs, such as the requirement for longer appointments.

Staff checked people’s health, care, and wellbeing needs during health reviews. At the last inspection we found medication reviews were not always adequately structured or managed in a way to protect patients. At this inspection we found improvements had been made and reviews sampled were mostly of a high quality. A care home representative told us that the practice worked well with them to ensure medicine reviews were carried out routinely and appropriately.

The service had effective systems to identify people with previously undiagnosed conditions.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. The practice told us they currently supported 1,751 patients with long-term conditions. Records we sampled showed these patients were effectively monitored with the exception of a small number of patients with high-risk diabetes, where follow up was mixed. The practice took prompt action to follow up these patients and shared the detailed action taken with us.

The service worked well across teams and services to support people. Feedback from staff was positive about how teams and different staff groups worked together to provide care and treatment.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice provided a service to 6 local care homes, providing care and treatment for the majority of the people accommodated. A care home representative for the older patient population told us ward rounds were undertaken weekly and were well-structured, with clear communication provided before, during, and after each visit. They said clinicians were familiar with their residents providing continuity of care, which helped with build trusting and effective relationships.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. People were supported to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Leaders told us they were looking to work with local secondary schools to help educate the younger population on healthy living options and smoking cessation. They advised they had developed positive working relationships with the local leisure centre where they could refer, or patients could self-refer for exercise on referral. A Winter ready event had also been hosted along with the primary care network (PCN) and the patient participation group (PPG) promoting local services and promoting self-care.

New patients and carers were offered health checks.

The service did not always ensure that outcomes were positive and consistent, or that they met clinical expectations. They had not met the national 95% target in all 5 childhood immunisation indicators. They were aware of their results and told us the challenges they had experienced despite promoting uptake. We saw the service had arrangements in place to follow up immunisation appointments when a child was not brought, or the appointment cancelled and not rebooked. The local Integrated Care Board (ICB) confirmed recent data for childhood immunisations was showing improvement.

The most recently published data showed the practice cervical screening uptake for their eligible population for both age groups within the last 3.5 years was below the national 80% target. The practice demonstrated they were putting in place appropriate measures to improve uptake. They had also completed an audit with their primary care network (PCN) focusing on patients from ethnic minority backgrounds, who were eligible for cervical screening as they had identified this group had a lower uptake of cervical screening.

Posters were displayed in the practice encouraging uptake for both screening and immunisations. We saw discussions about the need to encourage uptake had taken place during a management meeting held. They also considered the possibility of having dedicated clinics in addition to booking any reluctant patients in with the nurse for an informal discussion. Unverified data shared with us by the practice and the ICB showed an increase in uptake. The ICB advised us nationally and locally they were seeing lower uptake despite practices proactively working to engage with women to come forward for example offering out of hours sessions, direct bookings and promotional campaigns. They told us they would reach out to the practice and offer support and share any learning.

The practice told us they had 44 patients registered with a learning disability, of whom 39 were eligible for a learning disability review. As of January 2026, 30 reviews had been completed with a further 5 reviews scheduled. To ensure that all patients with learning disabilities received their annual review in a timely manner, the practice had implemented a number of actions demonstrating the practice’s commitment to patient safety, personalised care, and continuous quality improvement. These actions included continued oversight by the dedicated Data Quality (DQ) Assistant, flexible appointment scheduling, monitoring and reporting and continuous improvement and patient engagement.

Staff were able to share examples in relation to assessing capacity and obtaining consent. However, the practice did not consistently tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The practice had 118 patients coded as having a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) that documented peoples wishes in the event of emergency care. We sampled 5 patient records and found all were coded but only 2 plans were scanned onto the patient records. One consultation was very detailed regarding the patient wishes. Following our site visit leaders confirmed they had obtained copies of forms from 3 of the 4 large care homes and scanned these to patient records. A further care home was actioning the request and the service planned to obtain forms for housebound patients and discuss ReSPECT forms at the next clinical meeting. Clinical staff had received digital ReSPECT training. A care home representative told us ReSPECT forms were managed sensitively and professionally, with clear documentation and involvement of relevant parties where appropriate.

Where appropriate, patients were offered a chaperone for care and treatment. During our site visit we saw chaperone posters were displayed to inform patients of this service. Staff providing this service were provided with training.