Lindley Group 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 staff protected people from abuse and avoidable harm and made sure care was delivered from environments that were clean and well maintained.

At our last assessment, we rated this key question as requires improvement. The provider was in breach of legal regulation in relation to providing safe care and treatment. At this assessment we found a breach of legal regulation in relation to staffing and have asked the provider for an action plan in response to the concerns identified; the rating remains the same.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

There was a designated safeguarding children and adults lead at the practice. Staff knew who the lead was and how they could escalate any safeguarding concerns.

At the previous assessment in September 2025, it was identified that the provider’s safeguarding policy contained outdated guidance regarding training requirements, and that some staff had not attended a safeguarding training event and were therefore not trained to an appropriate level. At this assessment, the policy guidance remained inconsistent with current published guidance on safeguarding training requirements within GP practices. In addition, the provider was unable to provide evidence that staff who had previously not completed the required safeguarding training had since done so.

The safeguarding lead attended external safeguarding meetings and staff told us that safeguarding issues and learning was shared with them where appropriate.

All staff who acted as a chaperone had received a Disclosure and Barring Service (DBS) check, however some clinical staff had not received appropriate training for this role. The provider told us they would ensure this training was completed.

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.

The practice was situated in a 2-storey converted domestic property. Clinical services were delivered from the ground and first floors of the building, which were accessible by stairs.

There were processes in place for health and safety risk management. For example, risk assessments had been carried out and there was appropriate maintenance documentation in place, including portable appliance testing, medical calibration, electricity, gas and emergency lighting. Weekly fire alarm testing and yearly fire evacuation drills were also recorded. However, an external Legionella risk assessment carried out in March 2026 had identified several actions, some of which were classified as high-risk actions requiring completion within 3 months. At the time of our assessment none of these actions had been addressed.

There were gaps in health and safety training including display screen equipment and fire safety.

The provider had a business continuity plan which outlined how they should continue to operate in the event of a disruption.

At the previous assessment in September 2025, we identified issues in the provider's safe recruitment systems and processes, including missing recruitment documentation, as well as gaps in training records. At this assessment, we found that gaps remained.

We reviewed 1 staff file that had been examined during the previous assessment to determine whether the missing documentation had been obtained. While some of the outstanding documents had been secured, some were still not available. We also reviewed other longer-standing staff files and found gaps in documentation including photo-identification and immunisation history. We reviewed 1 staff file for an employee who had commenced employment since the last assessment. This file demonstrated improved recruitment processes, with only 1 required document unavailable.

All staff, with the exception of 2 non-clinical staff members, had an appropriate Disclosure and Barring Service (DBS) check in place. Where DBS checks had not been obtained, the provider had completed risk assessments to mitigate any risks associated with their roles.

The provider’s recruitment policy contained a ‘pre-employment checklist’ which did not include a GP Performers check. We reviewed 1 GP file and found there was no evidence that a Performers check had been carried out. After the assessment the provider amended their policy to include Performers checks at the point of recruitment.

We also identified ongoing gaps in training compliance. In addition, the provider was unable to evidence the level of training undertaken in some areas, such as mental capacity act and preventing radicalisation. Furthermore, the previous assessment in September 2025 had identified that there was no clear system in place to record or have oversight of role-specific training. We reviewed 2 training records and found that neither contained evidence of role-specific training which demonstrated this concern had not been appropriately addressed.

Since the last assessment the provider had put a system in place to monitor the professional body registration status of clinical staffto ensure renewals and registrations had not lapsed.

The provider made sure staff received effective support, supervision and development. There was a process in place to ensure staff had regular appraisals and staff we spoke with confirmed this. However, the provider could not locate some appraisal documentation at the time of our assessment. We saw evidence of clinical supervision processes including consultation reviews and prescribing audits for non-medical prescribers.

There were a range of clinical and non-clinical roles within the practice, which included GPs, nurses, a pharmacist and a health care assistant.

The provider did not always assess or manage the risk of infection appropriately.

There was an infection prevention and control (IPC) lead who had received specific training to support them in this role.

An IPC audit completed in April 2026 identified areas for improvement, and an action plan had been developed. However, the provider was unable to provide evidence of progress against the action plan or demonstrate that all actions had been completed. For example, 1 action was to display hand hygiene posters in all clinical rooms. During our assessment, we did not see hand hygiene posters displayed in either of the 2 clinical rooms we looked at. We also observed high-level dust in 1 clinical room, which did not support effective IPC measures.

At the previous assessment in September 2025, we found that the provider did not have an effective system in place to capture the immunisation status of staff in line with current guidance. At this assessment we found systems continued to be ineffective as gaps in staff immunisation records remained.

There were arrangements in place for managing clinical waste. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff, although some staff were unsure about how a spillage kit should be used.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.