Lapal 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 has changed to requires improvement.

We found breaches of regulation in relation to safe care and treatment. Staff managed most medicines well; but further improvements were needed in the management of long-term conditions, some MHRA alerts, and medicines that required regular monitoring or review. We also found safeguarding registers required a review to ensure they were up to date and contained all the relevant information.

Staff understood and managed most risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. However, some actions from fire and health safety risk assessments had not been actioned. There were enough staff with the right skills, qualifications and experience. Annual supervision and prescribing audit were carried out on a random sample of nurse prescribers. We were told that support conversations were in place for non-medical prescribers, however we were unable to gain assurances on how regular these were held. Managers made sure staff received training and regular appraisals to maintain high-quality care.

This service scored 56 (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. We spoke with a representative of the Chair of the patient participation group (PPG), and they felt the provider took concerns seriously and proactively made improvements to the service. Staff told us there was a process to raise concerns when things went wrong and they were informed of learning. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

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. However, we identified a systems issue which the provider was addressing.

The service had systems in place to process information relating to new patients and worked collaboratively with other providers to support shared care and transitions between services. Staff responsible for summarising and processing new patient records confirmed that summarising was both up to date and completed in a timely manner.

During our review of the referral management system, we noted that609 referral letters, dating from2014 to the present, were marked asunactioned. However, arandom sample of six recordsshowed that all had been appropriately actioned. The provider identified this as asystems issueand had contacted the system provider to resolve it. In the meantime, the service had designated a staff member to monitor and manage the errors, which were generating additional workflow prompts.

We found systems needed strengthening to ensure there were effective processes in place to maintain safeguarding registers. The processes in place were not regularly updated, and we identified gaps in the information held on people with potential safeguarding concerns. We reviewed a random sample of clinical records and found children’s records were not linked to family members on the register. For adults, there were no alerts in place to identify those on the safeguarding register.

Following the onsite assessment, we were told all adults on the safeguarding register had alerts added to their notes. The provider was also reviewing all the children on the safeguarding register to ensure they were linked to family members.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern.

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.

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 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.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Health and safety and fire risk assessments had been completed; however, the provider had not ensured that all actions identified within these assessments were addressed. While some actions were carried out following immediate verbal feedback from the external assessor, the provider was unaware of several outstanding items documented in the formal risk assessment report. This indicated a lack of oversight and governance in managing environmental risks and ensuring the safety of people using the service.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were Portable Appliance Testing (PAT) tested.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

The service made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision and development.

We found there was a range of clinical and non-clinical roles within the practice, and staff had received training relevant to their roles. Safe recruitment processes were in place. However, the provider had not assured that all staff working in clinical areas had received effective training and supervision to demonstrate competence in their roles. For example, a prescribing audit was undertaken on a random sample of nurse prescribers, reviewing 83 prescriptions issued between April and July 2025. While this audit was scheduled to be repeated annually, the previous audit had been carried out approximately 18 months earlier, which does not align with best practice guidance that recommends regular and consistent audit activity to support safe prescribing.

We were told that support was provided for staff who prescribed, however we found there was no documented evidence to demonstrate that clinical supervision or competency assessments were being carried out consistently.

While staff had received training for their roles, there was no definitive list of training which the provider identified as mandatory training for all staff. A list shared with us by the provider included topics such as infection control, health and safety, safeguarding adults and children, fire safety and warden duties, safety in general practice, mental health and dementia awareness, CPR, data and cyber security, and Prevent. We were told this was the training staff were required to complete. However, there was no evidence of a structured training matrix or oversight system to ensure completion, renewal, or role-specific training beyond this list. The practice management team confirmed that they were not aware of what training staff had completed.

There was inconsistency amongst the management team regarding who had completed training in sepsis. For example, not all members of the management team where clear or aware of who had completed the relevant training to ensure they had the knowledge and experience required to identify and appropriately signpost individuals requiring urgent attention. Staff records we sampled showed that relevant staff had completed sepsis training.

We were also made aware of issues regarding chaperone training. Chaperone training had been arranged for reception staff by the practice manager; however, three members of the reception team declined to participate.Following the site visit, we were informed that a chaperone training folder was kept at reception. This folder contained a record of staff who had completed chaperone training and a signed sheet for those who had declined. We were also told that a list of trained staff was displayed in every clinical room to ensure all staff were aware of who was available to act as a chaperone.

An induction programme had been implemented for new administrative staff. However, we found that not all members of the management team received an induction when they started, nor completed any formal training. This raised concerns about consistency and oversight in the onboarding process for senior staff.

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.

There were processes in place to manage the risk of infection. However, they needed to be further strengthened.

The ICB had conducted an IPC audit, and the subsequent action plan had been completed. However, this was completed in August 2023. As this should be conducted annually, a new audit was overdue. Following the site visit, the practice informed us that the requirement was then to undertake a self-assessment on a 6 monthly basis but there was a longer gap than anticipated. However, a new audit had been undertaken, and a digital reminder had been put in place to ensure it was not overlooked.

The practice had a designated infection, prevention and control lead and all staff had completed infection prevention and control training relevant to their role and staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely. Cleaning schedules were in place and followed.

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 provider did not have effective systems in place to manage and respond to safety alerts. We identified several historic alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA)that had not been appropriately actioned. These included alerts relating to citalopram (used to treat depression and anxiety),SGLT-2 inhibitors (used to manage type 2 diabetes), and aldosterone (a hormone that regulates blood pressure).

For example, 9 patients 9 patients prescribed a medicine typically used to treat depression and anxiety had not received all recommended monitoring tests and reviews. Clinical guidance recommends that patients aged 65 and over who are prescribed citalopram or escitalopram should receive annual ECGs to monitor QTc intervals. The lack of consistent monitoring increased the risk of harm and demonstrated a failure to act on known safety alerts.

Following the site visit, the provider reviewed patients flagged by the CQC and took steps to improve safety. For those prescribed citalopram or escitalopram, all nine patients over 65 were contacted for heart checks and medication reviews, with dose adjustments and risk discussions. Patients on SGLT-2 inhibitors were checked for missing safety advice. The provider found issues with how information was recorded and shared by hospitals. Safety information was sent to all remaining patients, and new processes were introduced to make sure risks are discussed and properly recorded in future reviews. For Aldosterone antagonists with ARB/ACE inhibitors, 11 patients were identified as overdue for renal function tests. Appropriate follow-up was undertaken, including contacting patients and retrieving hospital results. The provider committed to including these patients for ongoing monitoring by pharmacists.

Staff generally followed established processes to ensure patients prescribed medicines with specific risks received appropriate monitoring. However, clinical searches identified areas for improvement, including patients prescribeddirect oral anticoagulants (DOACs). The practice informed that they had actioned this following the assessment.

Staff managed prescription stationery securely. However, we found prescriptions awaiting collection dated back to June 2025, with no formal system in place to follow up on uncollected items. The provider acknowledged this and immediately introduced a new process to check the prescription box every three weeks and record the date of each review to ensure timely follow-up.

We reviewed 4 Patient Group Directions (PGDs). One PGD, which commenced on 1 September 2025, had not been signed by any staff member. The remaining PGDs had been signed by authorised staff but had not been countersigned by the manager.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients.