Sandy 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.

At our last inspection, we rated this key question as requires improvement. At this inspection, the rating has changed to good. The provider had made improvements in the following areas: infection, prevention and control, significant events, medicines management, the monitoring and recording of vaccines and safe recruitment practices.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last inspection we found some significant event records lacked detail of the risks and learning outcomes were not always noted on paper records held. At this inspection we found this had improved. 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. Staff were aware of the process for raising a significant event and were able to share a recent event, including the lessons learnt to identify and embed good practice to improve patient care. Staff felt leaders promoted an open culture, and that safety was a top priority.

There were 32 significant events recorded in the previous 12 months. Those we sampled had been reviewed, analysed and shared in line with policy. Significant events were recorded promptly, investigated, and discussed within a structured, non-blame framework. This enabled staff to reflect on practice, identify contributory factors, and implement actions to improve patient safety, quality of care, and operational effectiveness.

An annual significant event analysis (SEA) had been carried out which helped identify any key trends and themes. The most frequent trend identified was prescription-related issues followed by communication. Learning and impact had been identified to help reduce similar events from happening and improve patient care. Leaders told us SEA was a key component of the practice’s clinical governance framework, ensuring that incidents and near misses were systematically reviewed to promote learning, accountability, and continuous improvement across the team. Joint significant event and complaints meetings for clinicians at Sandy Lane Surgery and their sister practice were held every 8-12 weeks to share learning.

There was a system to record and investigate complaints. In the previous 12 months the practice had received 14 complaints, of these 4 were upheld, 3 partly and 7 were not upheld. Those we sampled were managed in line with policy and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. Complaints, including trends and themes, were shared with staff during meetings held. A representative from the Patient Participation Group (PPG) felt the provider took concerns and feedback seriously and proactively made improvements to the service. An analysis of complaints had been carried out looking at trends over the previous 4 years. There had been an increase in complaints in the previous 12 months, however most were not upheld. We saw 6 of the 21 formal complaints related to prescription queries. The practice had identified this as an area for improvement and collaborated with the reception team to develop and implement a new Standard Operating Procedure (SOP) aimed at reducing prescription errors. The service was committed to continuing to monitor trends, evaluate internal processes, and make necessary adjustments to enhance patient experience.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. 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. Referrals and test results were managed in a timely way.

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. Staff had access to a designated safeguarding lead and deputy should they have any concerns. The practice had carried out an audit and had identified 130 patients (1.44%) of their patient population as vulnerable patients. These patients were coded appropriately on the clinical system and had visible alerts on their records indicating their vulnerability status. The service acted on concerns working in partnership with other organisations.

Regular meetings were held to discuss vulnerable patients and any changing needs. Discussions held were recorded and where relevant information was shared with the local out-of-hours provider, for example patients identified at the end of their lives. The practice regularly attended meetings with Social Services, STARS Recovery (substance misuse), and the Community Matron.

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.

Emergency equipment was available with the exception of 1 item, which was promptly obtained post our site visit. Staff could recognise a deteriorating patient and knew of action to take. They were trained in sepsis awareness, anaphylaxis, cardiopulmonary resuscitation (CPR) and basic life support training. Staff told us they were comfortable approaching the clinical team for any advice. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service was located within a health centre, and the landlord was responsible for the maintenance of the building. Contracts were in place to ensure the premises was maintained. The service detected and controlled potential risks in the care environment. An annual health and safety risk assessment had been carried out covering all the rooms and areas used and risks identified had been addressed. The service made sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place which was monitored and reviewed.

At the last inspection we found recruitment checks on new staff had not been carried out fully and the service was not working in line with their recruitment policy. At this inspection we found identified shortfalls had since been addressed.

The service generally made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Most staff felt staffing levels were adequate, but they were expected to go the extra mile, which was not sustainable long term. Three GPs had left the practice to work overseas and had been replaced. Staff 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. Staffing updates were regularly shared during meetings held with the staff and the patient participation group (PPG). The practice had systems in place to ensure staff worked in an environment that was free of bullying and harassment. An electronic record was maintained detailing the training staff had completed. 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. Staff had protected learning time facilitated by the lead GP and the lead nurse.

The landlord, NHS Property Services, was responsible for maintaining cleaning standards across the health centre. At the last inspection we found appropriate standards of cleanliness and hygiene were not always maintained due to the exposed floor covering in toilets. At this inspection we found this had been addressed. 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 (IPC) lead and all staff had had relevant training and had access to an IPC policy. Cleaning schedules were in place detailing the task, frequency of cleaning and responsibility. An IPC audit had been carried out in June 2025 by the designated lead, which identified some required actions such as tears and holes in waiting room chairs, which had since been replaced with new seating. IPC measures had been discussed during a recent management meeting held. Staff were advised to consider wearing face masks and take additional precautions during the Winter period, for example when seeing patients with respiratory issues.

At the last inspection we found checks on controlled drugs held had not been carried out in line with policy and vaccine fridge temperatures were not being checked and recorded in line with recommended timescales. At this inspection we found these shortfalls had since been addressed.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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. They followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines, including controlled drugs, were stored securely however, room temperatures were not being monitored. The provider agreed to address this. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Medical gases, such as oxygen were stored safely. The service had effective systems to manage and respond to safety alerts and medicine recalls. Our remote clinical searches found established and effective processes were now in place to ensure people prescribed medicines with specific risks received the recommended monitoring.

The service had systems to log and track prescription stationery throughout the practice; however, these were not always effective and access was not adequately restricted. The provider told us they would address this.

The service was aware that the number of antibiotics, including broad-spectrum issued and the number of patients prescribed multiple psychotropic medicine were higher than the national average. They were taking steps to actively address this in addition to deprescribing powerful pain-relieving medicines in consultation with patients.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.