Sidley Medical Practice Also known as Dr Lawton & Partners

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 assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. The practice was unable to demonstrate that safety was a priority for everyone, and leaders had not embedded a culture of openness and collaboration. Significant events and complaints were not consistently identified, recorded, investigated, or shared and there was limited evidence to show that lessons were learned, or changes made to improve care. Systems, processes, and practices to make sure people were protected from abuse and neglect were unclear and not all staff were up to date with safeguarding training. The provider had not always ensured there were enough qualified, skilled, and experienced staff. In addition, staff did not always receive effective support, supervision, training, and development. The provider had not consistently taken steps to detect and control some of the potential risks related to fire safety. However, we found that risks to the prevention and control of infection were well managed. Our clinical searches found that people’s health was not always monitored in a way that ensured certain medicines were prescribed according to recommended guidelines. We also found the provider had not always effectively assessed and reviewed people’s care and treatment and maximised their outcomes. Not all the appropriate emergency medicines were held within the practice and risk assessments were not in place to determine the range of medicines held. The systems for monitoring stock levels, expiry dates and emergency equipment were not failsafe. We found breaches of regulation for the Safe key question and have told the provider to take action.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us that the practice had made some improvements because of feedback. PPG representatives described positive changes such as improved signage and an updated staff list. However, they felt some concerns were dismissed and lacked confidence in the complaints process.

Not all staff knew how to identify and report concerns, safety incidents and near misses. Those we spoke with were unclear about the practice’s policy and procedures for this and told us that if they did raise concerns, these were often ignored or dismissed. They told us they didn’t receive feedback about the learning or action from the significant events they did report. Leaders told us that significant events and complaints were discussed in meetings, but when we looked at meeting minutes, we found this was not always the case. Leaders acknowledged that oversight of the process for dealing with significant events and complaints needed to be improved.

Whilst the practice had a policy and procedure for dealing with significant events this was not consistently followed. Forms used for reporting significant events were often incomplete which meant there was insufficient evidence to show whether enough information gathering or investigations into root cause had taken place. Appropriate action and lessons learned were not always identified. The practice did not maintain an accurate or complete chronological log or central summary of significant events to enable it to monitor action and identify trends. We looked at the practice’s complaints records. We saw that actions agreed to be taken because of complaints had not always been implemented or followed up.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Interviews with staff indicated that some were unsure who the practice’s safeguarding lead was. Three staff members we spoke with were unable to demonstrate an understanding of safeguarding including how to identify and report concerns. Staff, including practice management, were unsure whether a safeguarding register existed or who managed it.

We did not receive any feedback about safeguarding from partner organisations.

The providers’ safeguarding policies had recently been updated to include named leads within the practice. The practice had not implemented its safeguarding policies sufficiently. There was no evidence of any safeguarding meetings or discussions. In addition, there was no evidence of a system to follow up on children who were not brought to their appointment, either at the practice or secondary care. Staff were not up to date with safeguarding training, and some were not trained to the appropriate level as set out in the practice’s policy.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff responsible for monitoring fire safety, health and safety told us that whilst both the main and branch surgeries had health and safety risk Staff responsible for monitoring fire safety, health and safety told us that whilst both the main and branch surgeries had health and safety risk assessments, only Sidley Surgery had had a fire risk assessment in January 2024. They told us that some actions identified in the risk assessments, for example the need to replace fire extinguishers were incomplete due to delays getting financial approval from the partners. Staff could not recall that there had been a fire drill at the branch surgery. After our assessment leaders identified that Albert Road fire drill and fire risk assessment was overdue and arranged for it to take place on 28th June 2024. After our assessment they arranged for the Albert Road fire risk assessment to take place on 15th August 2024. They also identified that the fire extinguisher at Sidley Surgery needed to be replaced and confirmed this this had been ordered.

During our assessment we observed the environment to be safe from visual hazards relating to health and safety and fire. For example, fire exits were clear. However, we observed that fire and health and safety risks were not always dealt with in line with the practice’s risk assessments.

Processes to monitor and maintain the safety and upkeep of the premises were not effective. The practice had not completed a fire risk assessment for the branch surgery, and they had not identified that a fire drill had not been completed to ensure staff were aware of the steps to take in the event of a fire. Areas requiring action as identified in the practice’s health and safety and fire risk assessments for the Sidley Medical Practice had not been completed. For example, the practice had not ensured that fire extinguishers had been replaced. Following inspection, the practice told us about actions they had taken to address these concerns.

People could not always easily get through on phone or get appointments that met their needs. They were concerned about the number of GPs that had left the practice over the past few years .

Staff and practice management told us there was insufficient staff to meet patient needs. Many were concerned that staffing levels were unsafe with delays in patients being seen and backlogs of correspondence, test results and prescription requests. They told us the practice had lost clinical and non-clinical staff over the last year and that insufficient staff had been recruited to fill the gaps. They told us that staffing levels made the work environment stressful and that they often worked above their contracted hours. Many felt the currents situation was unsustainable. Staff also told us that they were unable to complete required training and that arrangements for clinical supervision were insufficient. Feedback from practice leaders included that they were in the process of changing agencies who they used to provide clinical locum cover. They also advised that recruitment was difficult, and they had been unable to recruit a GP for a number of years. However, they had not risk assessed the impact of this.

The practice was unable to demonstrate how it ensured there were enough staff to provide appointments and prevent staff from working excessive hours. It was unable to provide a policy or risk assessment that determined minimum staffing levels and its approach to managing staff absences and busy periods. Recruitment checks to make sure that all staff were suitably experienced, competent, and able to carry out their role were not always complete.

We did not receive any patient feedback about the control of infection.

We spoke with the lead person with overall responsibility for infection control in the practice. They told us they had received training for their lead role and that they oversaw a programme of regular infection control audits. Staff and leaders told us that training on infection control was part of the essential training requirements for staff. However only 56% of staff were up to date with this.

We observed that clinical rooms were mainly clean, tidy and uncluttered. However we noted that some clinical rooms were carpeted, fans were dusty, and some furniture visibly worn.

The practice undertook regular audits of infection control. Audits carried out in March 2024 at both sites set out areas requiring improvement in action plan. This included dust in areas, carpets in consultation areas, blinds tatty/ broken, cracked tiles and general dustiness and clutter. At the time of the inspection the practice had not acted on all the issues identified.

People told us that they sometimes experienced delays to getting prescriptions. From our clinical searches, it was not always evident that people were fully involved in reviews of their medication. Some felt they had been prescribed the wrong medication.

Staff told us that arrangements for clinical supervision were insufficient. It was evident from discussions with staff and leaders that regular, structured reviews of their prescribing practice supported by clinical supervision or peer review had not taken place.

We observed that some of the emergency medicines, we would expect to see were not in stock. Risk assessments were not in place to determine the range of medicines held. We saw that appropriate emergency medical equipment was kept on site. However, systems for monitoring emergency medicines and equipment were not always effective. The practice did not hold all the appropriate emergency medicines, for example diazepam or midazolam, prednisolone, and dexamethasone. Risk assessments were not in place to determine the range of medicines held. There was medical oxygen and a defibrillator on site, however systems to ensure these were regularly checked and fit for use had failed to identify the lack of spare defibrillator pads. Systems did not identify whether equipment was in working order. It was not clear whether the practice had ordered spare pads. Vaccines were appropriately stored, monitored and transported in line with UK Health Security Agency guidance to ensure they remained safe and effective. It was noted that the temporary fridge at the branch surgery needed replacing to ensure there was sufficient space inside to store medicines safely.

Our clinical searches showed that processes to ensure people prescribed medicines with specific risks received recommended monitoring were not always followed. Reviews of people’s medication did not always follow good practice. The practice did not have effective systems to manage and respond to safety alerts and medicine recalls.

Patients’ health was not always monitored in a way that ensured the safe prescribing of certain medicines. This included medicines for heart failure, neuropathic pain and non-steroidal anti-inflammatory medicines.