Lees Medical Practice

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

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

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our review of clinical records indicated patients were supported to understand their condition and were involved in planning for their care needs. Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Feedback from the manager of a local residential home where the practice provided a GP service to a significant number of patients described that care and treatment was centred on individual needs and preferences.

The NHS GP Survey 2025 results however, trended towards a negative variation for people feeling fully listened to and involved in changes in their plans of care. The percentage of patients who felt listened to was 75% compared to the national average of 86%.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported continuity of care.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The uptake of childhood immunisation at the practice was high and, for one age group, exceeded the World Health Organisation target.

There were established mechanisms for engaging with the community healthcare providers and recent feedback (July 2025) from the commissioners and a care home manager, praised the leaders for effective integrated working and for ensuring continuity of care when people moved between services.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Leaders also took steps to work with individuals in aiding them to use new technology such as the NHS App. They had introduced processes to identify when people could not use the APP for various reasons, including digital exclusion.

The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard.

Information provided to patients by Lees Medical Practice had also been assessed by commissioners and awarded a certificate of achievement for accessibility.

Leaders worked with the patient participation group (PPG) and together had worked on providing a message board managed by the PPG with information about social support available and health promotion information.

The PPG were involved in developing an information video featuring the practice staff. Staff described their roles and scenarios when patients would be referred to them rather than a GP, the GP partner also participated in the video explaining when it might be better for patients to be seen by pharmacist rather than a GP.

The PPG also helped provide weekend open sessions where people could learn how to use the NHS App to access services.

Records confirmed people were able to share feedback and ideas, or raise complaints about their care, treatment and support, but they did not always feel updated about the outcomes of their input.

We saw complaints were managed in line with the practice’s policy. Learning from complaints was evident in staff training records, staff feedback, information in the complaints log and meeting records.

The NHS GP Survey 2025 results however, trended towards a negative variation for people feeling fully listened to and involved in changes in their plans of care. The percentage of patients who felt listened to was 75% compared to the national average of 86%.

Patients who provided feedback to CQC also told us they did not feel their concerns were dealt with fairly.

Patients told us they felt the service did not always make sure they could access the care, support and treatment they needed when they needed it, the most common reasons for this were: not seeing their preferred health professional; a sense that front of house staff were obstructive and problems with prescriptions being fulfilled.

Evidence provided by the service indicated that the majority of the time people were accessing the care, support and treatment they needed when they needed it. On the day of inspection, we saw that different types of appointments were available throughout the day, with different clinicians.

However, patients did not tell us this was the case.

The most recent NHS National GP 2025 survey showed patient satisfaction trended towards negative for ease of contacting the practice and scored 29% satisfaction compared to the England average 53%.

The most recent NHS National GP 2025 survey showed patient experience was significantly more negative when contacting the practice and scored 32% satisfaction compared to the England average of 70%.

Leaders also analysed the Google reviews Practice survey results. This was based on 33 responses between August 2024 and February 2025. This was unverified data. Leaders used the information to identify themes and trends so action could be taken to make improvements.

These findings related to attitude and professionalism of reception staff, sufficient phone lines at peak times and people feeling unable to access services digitally.

Phone were open from 8am. Actions taken by the practice in response to findings included: increasing the number of staff on the phones at peak times; the practices website was refreshed and updated to make it more user friendly; leaders provided patient education sessions on how to use the NHS App; administration and other staff were supported to complete medical receptionist training and other customer service courses and leaders introduced a pink card system to identify patients who needed to visit the service or telephone to access the service. Leaders also introduced a standard procedure checklist for staff to follow so that patients knew what to expect next after any contact with the service.

Leaders were also in the process of agreeing the most effective way of increasing and improving pharmacy input.

Patient feedback to CQC indicated these actions had not been in place long enough to demonstrate an improvement in patient satisfaction in relation to access. More time is needed to allow these changes to influence patient satisfaction.

The clinical and treatment areas were fully accessible to patients and visitors.

processes did not always enable leaders to actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Processes had been put in place to make improvements, however these need to be embedded.

Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including other practices to address any local health inequalities.

Clinical staff understood the importance of providing an inclusive approach to care. Leaders adjusted processes to support equity in people’s experience and outcomes, for example using flags and pop-ups to identify people who may need longer appointments; preferential home visits or exemption from using the NHS App or online booking process.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers.

Staff used appropriate systems to capture and review feedback from people using the service, including those who did not have access to the internet.

Patients, however, did not feel they had equal care and treatment. Leaders had introduced new processes to improve access which would also promote equal care and treatment. These changes needed time to embed before the impact could be reviewed through seeking feedback to measure improvements in patient satisfaction.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary. This could be improved if the pop-up alert function was activated in the medical records for these patients so that plans in place were immediately obvious and not just in the ‘problem’ section of the records.