Lees Medical Practice

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 assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

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.

Lees Medical Practice 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. Lessons were learnt to continually identify and embed good practice.

We saw from complaints records that patients were able to raise concerns, but many patients said this was not the case.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Managers encouraged staff to raise concerns when things went wrong.

During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. Staff told us they were treated with compassion and understanding from leaders.

The provider had processes for staff to report incidents, near misses and safety events.

There were systems in place and, a patient care co-ordinator has been employed to work directly with patients who needed additional support. During the inspection their priority was to record, investigate and respond to complaints. We saw instances that when things went wrong, staff apologised and gave people support to improve outcomes. This role commenced in March 2025 and is being embedded. Leaders believe this will help improve patient satisfaction and help patients to understand what has been learnt by investigating their concern.

Learning from incidents and complaints resulted in changes that improved care for others, for example a total triage system was introduced in response to complaints about access and this had resulted in an increase in routine checks. Staff training topics had also been changed to include more courses targeted towards customer service and probation period for potential new recruits had been modified.

Leaders 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.

Lees Medical Practice 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.

We completed clinical searches as part of the assessment processes. These searches demonstrated that the practice achieved best practice by flagging children on the child protection or at-risk register and linking them to members of their household.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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 and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Leaders detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. There had been a large turnover of staff in the previous 12 months, and new roles developed to meet the risk areas identified such as patient satisfaction and patient liaison. Action had also been taken to update recruitment policies and review the administrative and clinical staffing needs of the services.

Leaders were confident the change in the skill set of the newly employed staff would eventually improve outcomes and patient satisfaction. Clinical staff were supported and supervised by the partners and administration staff completed a robust induction program overseen by the experienced practice manager.

There were a range of clinical and non-clinical roles within the practice. 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. Safe recruitment practices were followed.

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 lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

All areas looked clean.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Records indicated they generally involved people in planning, including when changes happened. We saw that staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely.

As part of the assessment a CQC GP specialist advisor carried out a number of set clinical record searches to review medicines requiring monitoring. These searches were visible to the practice.A sample of patient records were checked to ensure the required monitoring was taking place. The clinical searches did not identify any significant shortfalls in patient medicines monitoring.

The clinical searches showed processes for dealing with alerts were in place and staff followed protocols such as responding to medicine alerts and considering best practice guidelines to ensure they prescribed medicines safely.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

The clinical searches included checking what was written for each patient during a medicine review. Medical records indicated reviews had been completed. It was noted that set templates were not always used. This was discussed with leaders during the search.

Feedback from patients indicated that the process for approving repeat prescriptions should be explained more clearly, especially in relation to medicines governed by strict rules concerning the number of repeats allowed without specific health checks.

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.

Staff managed prescription stationery appropriately and securely.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this and the number of antimicrobials issued by the provider was lower than local and national averages.

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