Leicester Terrace Health Care Centre

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. As part of our assessment, we reviewed the practice’s policies, spoke with staff via video calls, and carried out on-site observations. With the provider’s consent and in line with data protection requirements, we also conducted remote clinical searches of the patient records system. We reviewed patient records to identify any concerns and confirm the actions taken by the provider. The practice had clear systems and policies in place for recording and responding to significant events and complaints and these supported compliance with the duty of candour. Learning from events was shared and used to improve the practice. There were also effective systems for the safe and appropriate use of medicines, including medicines optimisation.

This service scored 72 (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 strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The practice promoted an open and transparent culture where concerns raised by both staff and patients were welcomed and seen as valuable opportunities for learning and improvement. Patients felt supported when raising concerns and reported that staff responded with empathy and compassion. Staff were proactive in addressing patients’ concerns, including non-clinical issues, aiming to enhance the overall patient experience. There was a clear focus on making a positive difference to each patient’s life and resolving issues promptly. For example, the practice proactively reviewed the notes of all patients who had died or received a new cancer diagnosis. Each month, the multidisciplinary team met to reflect on these cases, identifying any missed opportunities for earlier diagnosis or intervention. Findings were shared across the practice, leading to changes in clinical practice, targeted education, and enhanced patient safety.

Minutes from Patient Participation Group (PPG) meetings showed that members felt the provider was responsive to feedback and took concerns seriously, resulting in meaningful service improvements. For example, patients felt that the new triage system made sure they received appointments in a timely manner without having to wait. Managers fostered a culture of openness, where staff felt empowered to speak up when issues occurred. Incidents and complaints were thoroughly reviewed, with learning used to implement changes that enhanced the quality of care. Staff meetings were held regularly, creating space for reflection, shared learning, and team collaboration. The provider adopted a proactive approach to incident review at all levels, and key learning was often shared across the wider Primary Care Network (PCN) or Integrated Care Board (ICB) to support continuous improvement within the local health system. Staff consistently described a culture of openness, underpinned by a strong focus on safety. Clear systems were in place for reporting incidents, near misses, and learning events. When errors occurred, staff were open, offered apologies, and provided support to those affected.

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.

Systems for managing information related to new patients were current and effectively maintained.For urgent referrals, a tracking and auditing system had been introduced, allowing the administration team to monitor progress and ensuring that the referring clinician reviewed the outcome and provided appropriate follow-up for the patient. Referrals and test results were managed promptly, and a dedicated team of administrative staff was in place to support patients in safely transitioning between services. The practice worked collaboratively with other providers to ensure continuity of care, particularly when patients were receiving shared care or moving between services. Correspondence was handled promptly, reviewed by appropriate staff, and acted upon to maintain safe and effective care. Clear processes ensured that referrals and test results were managed without delay.

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. Safeguarding policies were in place and clearly understood by staff, all of whom had received training appropriate to their roles. The practice maintained an up-to-date register of vulnerable patients and worked closely with external agencies to respond to concerns. The practice had both adults and children’s safeguarding leads who regularly reviewed cases and relevant information which was shared within the team to ensure coordinated and effective care. The practice had a dedicated section on their portal for safeguarding with easy access to the local safeguarding directory and details of how to make a safeguarding referral or obtain advice which was available to all staff.

Staff were confident in recognising and reporting safeguarding issues and knew how to access the safeguarding lead when needed. Electronic alerts on patient records helped clinical staff identify potential safeguarding risks. Regular meetings were held with professionals such as social workers, health visitors, collaborative care teams and care co-ordinators to ensure the safety and wellbeing of vulnerable adults and children.

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. Staff were trained to identify signs of deterioration and were confident in taking appropriate action. A duty doctor was available each day to provide support for patients requiring urgent attention and emergency equipment was available and maintained. Staff were also trained to recognise symptoms that may indicate the need for immediate medical intervention.

The service identified and managed any risks in the care environment to help keep people safe. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Staff had completed relevant training, including health and safety, fire safety, and information governance. The premises and facilities were suitable for the services provided, and equipment was well maintained and fit for use. There was a business continuity plan in place which was monitored and reviewed. Leaders had made reasonable adjustments by providing a designated access consultation room available on the ground floor for patients who were unable to use the stair lifts or required a step-free access to clinical services. The reception desks and waiting areas were positioned at accessible heights with seating provided for those unable to stand for long periods of time.

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.

The practice employed a diverse team of clinical and non-clinical staff who worked collaboratively to support patient care. There were effective systems in place to ensure that staff training was kept up to date, with ongoing management of learning needs and professional development. Staff were encouraged and supported to develop new skills and undertake additional training to enhance their abilities and career progression. Many staff members had long-standing employment with the practice, with some advancing to more senior positions through internal support. For example, a nurse who had completed their training at the practice chose to return after qualifying, reflecting the supportive and positive learning environment. A strong process was in place to ensure staff worked within their defined competencies. The practice regularly conducted audits of patient-facing roles to ensure accurate documentation, prescribing, and treatment planning. Results were clearly recorded, and any learning outcomes were shared within the team to improve overall knowledge. Non-clinical staff, including administrative staff had regular appraisals and recruitment procedures were thorough.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The leaders ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The practice had a designated infection, prevention and control (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were undertaken. During our visit, we identified that some sinks did not meet infection prevention and control (IPC) standards. Clinical hand-wash sinks are expected to be designed in a way that supports safe and effective hand hygiene, for example by having taps that can be operated without using hands, no plugs or overflow features, and surfaces that can be easily cleaned to reduce the risk of contamination. The sinks we reviewed did not fully meet these requirements. However, the practice provided evidence that plans to replace the affected sinks had already been agreed and initiated before our inspection.

Records of staff immunisation status were maintained. All staff received an occupational health assessment which included a review of their immunisation needs. Where required a risk assessment was undertaken for individual staff.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Clinical searches carried out were found to be safe. Our review found no evidence of any missed diagnoses for patients and there were clear systems in place for patients on prescribed medicines which require monitoring. We found that for DMARDs (Disease-modifying antirheumatic drugs) medications that treat autoimmune diseases had safety measures in place to make sure they were managed correctly. Our clinical record searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We reviewed a random sample of 5 patient records. We found that 5 out of 5 patients had been followed up within a timely manner.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. For example, the clinical pharmacy team ran weekly and monthly structured searches, supported by data outputs that identified patients due or overdue for monitoring. These patients were proactively invited and followed up to ensure timely tests and safe prescribing. Medicines were stored securely and maintained at appropriate temperatures. The practice provided patients with guidance on correct home storage of medicines where required. Regular stock checks were carried out for all medicines, including emergency supplies and vaccines, with attention to expiry dates. The provider had effective systems to manage safety alerts and medicine recalls promptly.