Lakeside 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 good. At this assessment, the rating remains the same.

Patients were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Managers made sure staff received training to maintain high-quality care. Staff managed medicines well and involved patients in planning any changes. Patients were able to raise concerns; however we found incidents were not always used to drive improvement.

This service scored 66 (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 did not always have a proactive and positive culture of safety, based on openness and honesty, but had identified this as an area for improvement. The provider had processes for staff to report incidents and staff told us they felt supported to raise concerns. However, some staff reported that they did not always have the opportunity to discuss incidents and associated learning outcomes. We were not assured that all incidents were formally recorded. We reviewed the practice’s incident log and there were 2 recorded incidents in the last 12 months. There were a further 2 incidents that had been recorded but were awaiting investigation and discussion with the relevant team members. By failing to identify and discuss all significant events or incidents, there was a risk the practice was missing potential learning opportunities to embed good practice.

The service worked with patients 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 patients 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. There were processes in place to ensure urgent results and correspondence were actioned on the same day, and routine results and correspondence were actioned within 48 hours.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ 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.

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

The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet patients’ needs that was safe, supportive and enabled patients 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.

The service 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 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. During our review of recruitment records we found one member of clinical staff had a standard DBS check. Guidance for NHS employers within the DBS eligibility tool stated that individuals carrying out any form of healthcare were eligible for an enhanced DBS check. The provider told us they believed this individual did have an enhanced DBS check however, was unable to provide evidence of this.

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 made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. They involved patients in planning, including when changes happened. We conducted searches on the practice’s clinical records system. We found that most patients had received appropriate monitoring for the medicines they were prescribed. In cases where monitoring had not been carried out, we saw there had been a number of attempts to encourage patients to attend for monitoring tests using different methods of communication. We found that staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely.

We reviewed 5 patients aged over 65 years who were prescribed oral non-steroidal anti-inflammatory drugs (NSAIDs) (medicines used to relieve pain or reduce inflammation) or aged over 75 years and prescribed an antiplatelet (medicines used to prevent blood clots). National Institute for Health and Care Excellence (NICE) guidance, states that patients in these age categories prescribed these medicines should be considered for a prescription of a proton pump inhibitor (PPI) to prevent gastrointestinal adverse effects. Of the 5 patients reviewed, we found none of the patients had been prescribed a PPI. We shared our findings with the provider who reviewed these patients. Two patients were subsequently prescribed a PPI. The remaining 3 patients were reviewed and found to not need a PPI.

We reviewed 5 patients prescribed a medicine that required regular blood pressure monitoring. We found 2 patients had not had recent monitoring tests. We shared these findings with the provider when we carried out the clinical searches on 8 July 2025. During our site visit on 10 July 2025, we saw that both patients had an up to date blood pressure recorded within their clinical notes.

We reviewed Patient Group Directives (PGDs) which allowed nurses to administer vaccinations. We found all the PGDs viewed had not been signed by a suitable person at the practice. This meant that nurses at the practice did not have the correct authorisation to administer these vaccines. Following our feedback, a prescriber signed the PGDs to give authorisation to the staff members named on the documents.

Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. 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. The provider had effective systems to manage and respond to safety alerts and medicine recalls. 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 in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.