Lindley Group Practice

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• 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

The practice had a good learning culture, staff could raise concerns, and managers investigated incidents thoroughly. There were systems and processes in place to support medicines management. A review of patient clinical records found that overall patients’ medicines and treatment were safely managed by the practice. However, we found some gaps in systems and processes around safe and effective staffing and infection prevention and control (IPC) which could potentially impact on patient safety.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice demonstrated a proactive and positive culture of safety, based on openness and honesty. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly.

The practice had systems and processes in place, underpinned by policies, to formally manage incidents and complaints. During this assessment we reviewed a selection of incidents and complaints and saw appropriate action had been taken as well as learning shared through meetings. At the time of our assessment, the practice did not have a system to collectively review incidents and complaints to identify themes and trends but indicated they would initiate this as part of their audit programme.

We saw that accident and incident reporting was part of the practice’s mandatory training schedule. Staff were able to explain the process of how they would report an incident, or who they would seek guidance from to do so. Staff told us they were encouraged to report incidents and felt confident to do this.

The practice had formal systems and processes in place to manage referrals, clinical correspondence, pathology results and medical record summarising.

We observed that urgent 2-week wait cancer referrals were dealt with appropriately and in a timely manner. The practice demonstrated their system which tracked that a patient had attended for their appointment and that outcome correspondence had been received.Incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications, which was undertaken by the pharmacy team.

Pathology results were actioned by clinicians and there was a system in place for when staff were absent. There was a process in place for safety-netting cervical screening to ensure that a result was received for each cervical screening sample undertaken.

Clinical records of new patients were mostly received by electronic transfer and those that were received in paper form were summarised in the practice’s clinical record system. We saw that the practice had summarised 96% of patient records. At the time of the assessment, the practice had not completed a formal audit of the summarising process but advised us that they would add this to their audit schedule to ensure medical records were summarised in line with their protocol.

The practice had a clinical safeguarding children and adults lead and deputy in place. Staff knew who the leads were, how to escalate safeguarding concerns and were able to give examples of what would constitute a safeguarding concern.

At the time of our assessment, the safeguarding policy contained some out-of-date guidance, which included training competency. This impacted on the level of safeguarding children and adults training the practice had recorded as required for administrative staff appropriate to their role. After the assessment, the practice reviewed and updated their policy.

The majority of clinical and non-clinical staff had attended an external safeguarding training event in September 2025, which was equivalent to safeguarding children and adults level 3. At the time of the assessment, the practice was facilitating the training of those staff who had not completed appropriate safeguarding and preventing radicalisation training relevant to their role.

The practice had systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations.

As part of our assessment, we reviewed safeguarding registers and some patient records with the safeguarding lead. We found appropriate safeguarding coding and flagging, which included household-level linking, in the clinical system.

The safeguarding lead attended external safeguarding meetings and held regular multidisciplinary meetings where safeguarding was discussed and documented.

Staff who acted as a chaperone were trained, but not all staff who told us they had acted as a chaperone had received a Disclosure and Barring Service (DBS) check relevant to their role. At our on-site assessment we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

Staff were confident in the systems and processes to respond to medical emergencies. Non-clinical staff demonstrated they were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient. The practice had provided care navigation and sepsis awareness training for staff. There were safety-netting prompts integrated within the practice’s clinical system for care navigation staff to follow to ensure patients were appropriately signposted. This system was supported by a daily triage duty GP.

At our on-site visit, we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. The practice had undertaken a review of the emergency medicines they held, based on local context and the services they provided, and a risk assessment had been undertaken to support these decisions. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place which were recorded. Records confirmed that all staff had completed basic life support training which was updated annually, either by face-to-face training or an on-line training module.

Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their computer desktop.

The practice was situated in a 2-storey converted domestic property. Patient services were delivered from the ground and first floors of the building, which were accessible by stairs. The practice also had a portacabin in the car park, which offered an additional consultation room. The practice told us that patients with ambulatory difficulties would be seen in a ground floor consultation room. The practice discussed that one of their biggest challenges was the space constraints with their current premises which impacted on their ability to extend the service provision, recruit more staff, and offer a fully accessible service.

During the assessment, we found maintenance documentation in place for electricity, portable appliance testing (PAT), medical calibration, the fire detection system, fire extinguishers, emergency lighting, the intruder alarm and the closed-circuit television (CCTV). The gas safety certification was overdue its maintenance.

The practice had undertaken their own risk assessments for fire, Control of Substances Hazardous to Health (COSHH), health and safety and Legionella. The practice had not been undertaking any water temperature testing of the premises. We discussed with the practice that there were no requirements about who carried out premises risk assessments other than they should be assured that the nominated person had sufficient knowledge, training and experience.

There was a fire policy in place. Weekly fire alarm testing was undertaken and recorded. A fire evacuation drill had been carried out in December 2024, which the practice told us was undertaken annually. There were named and trained fire marshals. The majority of staff had undertaken fire awareness training in the last 12 months. The practice also included health, safety and welfare, display screen equipment (DES), electrical safety and COSHH as part of their training schedule for staff.

As part of our assessment, we looked for evidence of safe recruitment and found gaps in systems and processes to ensure appropriate documentation was in place. We identified that 2 clinical staff did not have Disclosure and Barring Service (DBS) checks to a level relevant to their role. In addition, we reviewed the recruitment files of 4 clinical staff members, one of whom was a regular locum, and 1 non-clinical staff member, all of whom had commenced since our previous inspection. We found there were gaps in documentation which included photo-identification, appropriate reference checks, confirmation of entry on the GP performers list and documentary evidence of relevant qualifications.

The practice told us they had a system in place to check the relevant professional body registration status of clinical staff at the point of recruitment. However, there was no system in place to monitor these after the initial recruitment phase to ensure renewals and registrations had not lapsed.

Staff we spoke with told us they had undertaken an induction when they had commenced which was tailored to their roles and included a period of shadowing with colleagues. The staff files we reviewed did not contain a copy of the induction paperwork as a record.

The practice had identified mandatory training for clinical and non-clinical staff. We found some training was not on a level and frequency in line with guidance and there were some gaps in up-to-date training. After the assessment the practice told us they had facilitated time for staff to complete mandatory training. There was no clear system in place to record or have oversight of role-specific training. For example, the nursing team, to ensure that training relevant to their skillset and role were documented and up-to-date.

There was a process in place to ensure staff had regular appraisals and staff we spoke with confirmed this. Clinical staff told us they had a clinical supervisor, debrief sessions and that there were regular clinical meetings where cases were reviewed. They told us they felt fully supported clinically from all GPs and that there was an approachable ‘open-door’ policy. The practice undertook reviews of consultations and prescribing of staff employed in advanced clinical practice.

The practice supported staff development, and we saw that some staff who had commenced as an apprentice were now employed by the practice.

The practice had recently nominated a practice nurse to the role of infection prevention and control (IPC) lead following the retirement of the previous nurse lead. We saw that training to support them in this role had been booked for November 2025.

The practice manager and a GP partner had undertaken an IPC audit in October 2025. We saw that IPC and hand hygiene training formed part of the practice’s mandatory training schedule, and the majority of staff had completed this to a level appropriate to their role in the last year.

The practice did not have an effective system in place to capture the immunisation status of staff in line with current guidance, and we found gaps in the records reviewed.

Cleaning was undertaken by contract cleaners, who had access to appropriate colour-coded equipment and cleaning materials in a dedicated locked area. On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free.

The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including the management of sharps injuries and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff.

As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. These searches included patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines which required patient monitoring, medicines subject to a patient safety alert, medicines usage and medicines reviews. Overall, we found systems in place to ensure patients were managed in line with guidance. We highlighted some patients from the searches for further review and received written feedback from the practice.

We found 45 patients were prescribed the DMARD methotrexate, of which 3 did not appear to have had monitoring in the last 6 months. We reviewed these patients and found that they were being managed in secondary care.

There were 1,071 patients prescribed an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), which are used to treat raised blood pressure. We found 12 patients were overdue monitoring. We reviewed 5 patient records and found the practice had sent multiple reminders for follow-up and where appropriate the quantities of medicines had been reduced.

There were 7 patients prescribed the combination simvastatin and amlodipine, which were the subject of a 2014 drug safety alert as potentially increasing the risk of muscle damage. We reviewed 5 patients and highlighted 4 patients for further review. After the assessment the practice provided written feedback on their ongoing management.

There were 94 patients prescribed an oral non-steroidal anti-inflammatory drug (NSAID) over the age of 65 or an antiplatelet over the age of 75 who had not been prescribed a protein pump inhibitor (PPI) in line with guidance. We reviewed 5 records and highlighted 2 patients for further review. We received written feedback from the practice as to their ongoing management.

There was a process in place for the safe handling of requests for repeat medicines and evidence of medication reviews for patients prescribed repeat medicines. We reviewed a sample of medication reviews undertaken in the last 3 months, of which there were 1,250, and identified no concerns in the quality of the reviews.

At our on-site visit, we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions.

Blank prescription stationery was securely stored, and their use was monitored in line with national guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that prescribing outcomes were broadly in line with average outcomes.