Leander Family 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 Good. At this assessment, the rating has changed to requires improvement.
The service was in breach of legal regulation in relation to Regulation 12 of the Health and Social Care Act. Safe staff recruitment checks were not always followed. Monitoring patients on high-risk medicines was not always sufficient.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.
People felt supported to raise concerns and felt staff treated them with compassion and understanding. 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. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The practice had received 20 complaints in the last 12 months. Learning from incidents and complaints resulted in changes that improved care for others.
The significant event policy had been reviewed in April 2025. Staff reported a learning culture where staff were encouraged to report significant events which would foster learning and help prevent the recurrence of similar incidents in the future. The lead GP went through a significant event that they used as a learning event where processes were changed because of the event. This demonstrated that they had systems in place to review and learn from events when things went wrong or concerns were raised.
 

The service 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.
 

The service 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 saw separate adult and child safeguarding policies that had been reviewed in April 2025. Staff were aware who the safeguarding lead was. The practice had oversight of a list of vulnerable people that was reviewed regularly. We reviewed 5 staff training files and identified that one clinical staff member had not completed safeguarding training for adults or children. When this was raised the practice manager told us they would make sure all staff had completed safeguarding training.

The service worked with people to understand and manage risks in most cases, 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. Equipment and medicines were stored in a central place which was accessible to all staff. Staff we spoke with were aware of what to do in an emergency. All staff were trained in basic life support. 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.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The practice manager had oversight of contracts and maintenance for equipment, and the landlord had responsibility for the maintenance of the building.
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.
We saw the practice had undertaken portable appliance and calibration of electrical equipment testing.
Fire alarm tests were carried out weekly and fire extinguisher checks were carried out annually. The practice had 3 fire wardens.
A health and safety risk assessment had been undertaken by an external company in April 2026, there were a few actions, all of which had been addressed.
 

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, the service did not always ensure relevant recruitment documents were obtained. We sampled 5 staff files and identified that the files of 2 staff members (one clinical and one non-clinical) did not have an application form or CV, for 2 clinical staff there were no references and one clinical staff member had not signed a confidentially agreement. Out of the sample of 5 files reviewed, 4 staff had not had an appraisal. The provider informed us they were in the process of completing all staff appraisals.
There were a range of clinical and non-clinical roles within the practice. Generally, we found training was up to date, however out of the sample of 5 staff files reviewed one clinical staff member had not completed safeguarding children or adults, 3 staff had not completed mental capacity training, and none of the 5 staff had completed training to support people with a learning disability and autistic people. The provider told us they were not aware staff needed to do this training and would get staff to complete it.
We also found that staff files did not always contain details of staff members’ immunisation status. The provider informed us they were working on ensuring updated records were obtained and recorded.Staff were working within their agreed areas of competence.

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.
 

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. The monitoring of patients on high-risk medicines was not always sufficient, this meant people’s needs were not always safely met.
The service had a protocol for prescribing medicines that require specific monitoring. We looked at some examples of people prescribed some of these medicines. We found that for one medicine prescribing followed the protocol, but for other medicines the prescribing was inconsistent. Not all the people we looked at had the recommended required monitoring or medicines reviews and some people had not been coded correctly as having monitoring done.
There was not consistent evidence of action to encourage people to attend to have the monitoring.
Following our site visit, the provider reviewed all the patients we identified concerns about and submitted an action plan showing how they were going to address the issues found during our inspection.
We found the provider did not have all the recommended emergency medicines. When we raised this the provider informed us, they had a pharmacy next door to the practice and they had undertaken a risk assessment for not having these medicines, however this was not formally documented.
Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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.
Daily records of the maximum and minimum temperatures of the fridges were recorded. Staff were aware of what to do if any fridge had temperature readings outside of the required range. All fridges were lockable to ensure only authorised staff could access them.
Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. 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. There were suitable processes for staff to follow when dispensing medicines (dispensing practices). 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. For example, 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.