Leylands Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to outstanding.

This service scored 92 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. For example, results from the National GP Patient Survey (2025) confirmed that 98% of respondents felt the healthcare professional they saw had all the information they needed about them during their last general practice appointment (national average 92%).

Staff were aware of the needs of the local community. There was a system in place to highlight any specific individual needs, such as a requirement for a longer appointment or use of a translator, on the clinical system. Staff could refer people with social needs, such as those experiencing isolation or housing difficulties, to a social prescriber.

The practice operated a triage-first access model, and to support this had redesigned the clinical workflow to ensure that every patient request could be assessed safely, effectively and consistently. When assessing requests from patients, clinicians utilised a dashboard which clearly flagged information including frailty score, triage contacts within the last 12 months, GP appointments within the last 12 months and patient summary and pre-existing health problems. Further information such as pathology and cytology results could also be easily accessed from the dashboard. This enabled clinicians to carry out a thorough assessment of the patient, consider all relevant factors and improve patient responsiveness and access outcomes.

The provider had effective systems to identify people with previously undiagnosed conditions. The practice had undertaken a range of quality improvement activities aimed to enable proactive, detailed assessment of patients. This included prevention of cardiovascular disease by improving access to lipid lowering therapies, increasing the detection of high blood pressure and an automated hypertension protocol.

We reviewed case studies where patients’ health issues had been identified proactively during NHS health checks as a result of the quality improvement work and appropriate action taken. For example, elevated cardiovascular risk and commencement of appropriate medication, diagnosis of type 2 diabetes and referral to the nursing team and long-term conditions team for onward management. In all cases, relevant action was undertaken by the practice without the need for the patient to reattend. We saw how the processes in place ensured the patient was kept informed of all findings and supported to engage with treatment.

The practice always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation.

The practice adopted a holistic approach to long-term conditions (LTC) management. They had implemented a dedicated LTC administrative team who had a good understanding of monitoring requirements and identified opportunities to ensure monitoring was carried out opportunistically. We reviewed a case study outlining an example of this when a patient had blood tests arranged following an episode of acute care. A member of the LTC team recognised that the patient’s LTC review was also due and therefore amended the pathology request to include the relevant LTC testing, the patient was booked into the appropriate LTC review pathway rather than a standard phlebotomy appointment. This enabled the follow-up needs and routine monitoring to be addressed during 1 process.

Leaders at the practice had implemented systems to prevent missed diagnosis by creating automated alerts when blood test results suggested pre-diabetes or possible diabetes. The alert would prompt the clinician to review the result, check the diagnosis and take appropriate action. A further prompt was then sent to the LTC team to ensure the patient record was coded appropriately and followed up by a clinician, appropriate appointments had been made, and the patient had been informed of the findings. As a result of this work, 4,497 patients had received a LTC review in the previous 12 months.

As part of our assessment, a CQC GP Specialist Advisor (SpA) carried out a series of remote clinical searches of patient records to assess the practice’s processes around the management of patients with a LTC, for example asthma, chronic kidney disease, diabetes and hypothyroidism. Overall, we found the practice had good management of these patients.

The practice always worked well across teams and services to support people. Information was shared between services via the clinical system. Leaders from the practice held additional roles which promoted integrated working. For example, a GP partner was also the Primary Care Network (PCN) clinical director.

The practice proactively sought feedback from other services. As part of our assessment we reviewed feedback obtained by the practice in October 2025 from other services including PCN practices, local physiotherapy services and district nursing teams. Feedback included comments such as supportive, responsive, approachable, collaborative to describe staff and the practice as a whole.

We saw examples of proactive joint working including:

Grief and loss counselling: The practice had identified a gap for counselling and the need for accessible, community-based grief and loss support. This was addressed by utilising funds from the practice budget with work with a The Cellar Trust (a local organisation specialising in bereavement support) to provide regular counselling clinics at the practice. The service provides support to approximately 15-30 patients each month and has been fully utilised since inception.

First Contact Mental Health Service: The practice had identified a recurring group of patients contacting the practice with mental health concerns who did not meet the threshold for the mental health practitioner or secondary mental health services, but whose needs could not be met during a standard GP consultation. In response to this, the practice worked in collaboration with Mind Foundation to develop a first-contact mental health service. The practice utilised funding to allow patients access to a 16 hour per week telephone clinic, providing structured mental health assessment, support and signposting. This has resulted in 32 patients per week, having access to front line support and signposting.

Ultrasound guided injections: The practice had developed an in-house ultrasound guided injection service within the musculoskeletal (MSK) pathway. This involved funding specialist training for a senior MSK clinician, investment in equipment and sourcing experienced external clinical support from an established local MSK service to help safely embed the model. This enabled them to provide patients with a timelier service, closer to home and avoided the need for them to be referred to a hospital setting for the procedure, therefore reducing pressure on hospital waiting times.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice had undertaken a review and redesign of the internal clinical communication system and created a one-click communications hub within the clinical system. This enabled clinicians to access protocolised workflows to arrange internal appointments, signpost patients externally, request investigations, send structured internal communications and submit cases to the weekly complex patient multidisciplinary meeting. The new system ensured that all information was captured including timeframe and relevant clinical context, ensuring administrative teams received consistent information and receiving clinicians had a clear understanding of why the patient is attending.

The practice always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support. For example, we saw evidence of numerous quality improvement projects undertaken by the practice which aimed to reduce health inequalities for the local population. This included:

Raising awareness of diabetes: Recognising that Type 2 diabetes is highly prevalent in the locality and contributes significantly to cardiovascular disease, avoidable illness and reduced quality of life, the practice had undertaken a targeted outreach and engagement focusing on higher-risk patients with pre-diabetes. This was aimed at patients who had not taken up the offer of referral to the National Diabetes Prevention Programme (NDPP) and higher-risk patients who would most benefit from intervention. Through a combination of patient surveys and hosting an in-house diabetes prevention awareness day at the practice, the practice was able to identify barriers to engagement with NDPP and work to address these. For example, improvements to in-house communication strategies to include personalised diabetes risk numbers, clear explanation of the benefits of prevention and direct links to success stories and programme information. The practice shared information with the NDPP provider regarding timings of programme sessions, which some patients found difficult to attend and suggestions for improving how the programme is promoted.

Increasing the detection of high blood pressure: Implementation of a system-based hypertension detection and management programme aligned with NICE guidance to address undiagnosed hypertension within a high-risk population. This project was rolled out in phases commencing early 2025, steps taken included expanding NHS health checks to improve preventative engagement, dedicated staff members for requesting home readings and informing patients why these were important, proactive follow up and implementation of standardised standard operating procedures for blood test, urine and Electrocardiogram (ECG). This enabled the long term conditions team to arrange tests without clinical input, ensuring everything was ready for the next stage. This work resulted in the hypertension register increasing by 10%, with the number of patients reaching their target blood pressure rising by 4% as of January 2026.

Staff demonstrated a commitment to identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

Leaders at the practice had recognised the need to increase uptake of vaccination and screening and in May 2025 had implemented a number of projects to address this including:

Make every contact count - a new practice wide approach to screening and vaccination: By utilising bespoke digital infrastructure, any staff member (both clinical and non-clinical) could easily identify outstanding preventative care needs and take steps to address these by sending invites containing a booking link by text message, accessing a verbal script to discuss benefits of screening or accurately recording a decision to decline.

Non-clinical staff who had never been involved with patients regarding vaccination and screening were supported to proactively engage using behavioural nudge theory scripts aimed to explain the process to patient and reduce barriers to uptake.

A structured drive to increase uptake of cervical screening: In May 2025 the practice also expanded nurse capacity, introduced a structured recall system based on the patient’s month of birth and introduced repeated invitations and behavioural prompts to improve engagement and uptake.

As a result of the above projects, patients could access cervical screening throughout the week with additional extended-hours access. Completed procedures increased from 305 in the 6 months prior to May 2025 to 439 in the 6 months following implementation, demonstrating a 44% increase in uptake.

Verified data published by NHS England indicated that the practice had not achieved expected uptake for cervical screening. For example, as of 30 June 2024, 49.8% of people aged 25 to 49 had received an adequate screening test within the last 3.5 years (expected 80%) and 67.2% of people aged 50 to 64 had received an adequate screening test within the last 5.5 years (expected 80%). However, following the improvement work detailed above, unverified data provided by the practice indicated that at the time of our assessment 86.5% of people aged 25 to 49 had received screening and 97.4% of people aged 50 to 64 had received screening.

A structured approach to improving childhood immunisation rates: The practice identified that many children were missing or delaying routine vaccinations due to vaccine hesitancy and the lack of a reliable, auditable recall system. In response to this, a full record review was undertaken of all children born since January 2022, introducing a structured recall process and formally documenting each contact attempt to enable full tracking.

As a result of this work the practice had noted an increased uptake of 32% for 6-in-1 vaccines, 161% increase for measles, mumps and rubella (MMR)/measles, mumps, rubella and varicella (MMRV) vaccines and a 28% increase for meningococcal group B (MenB).

Clinicians at the practice were very aware of high levels of vaccine scepticism within the patient population and demonstrated a clear commitment to continuing this work.

Patient engagement and outreach - pregnancy and childhood vaccinations in deprived communities: Leaders at the practice had also identified low uptake of pregnancy vaccinations within the population. In response to this they had approached a local charity to discuss ways to address this. In conjunction with the charity, the practice engaged with pregnant women through community events, support groups and targeted outreach to increase awareness and uptake of pertussis, Respiratory Syncytial Virus (RSV) and influenza vaccines in pregnancy.

Between August 2025 and February 2026, the practice engaged with 209 individuals including pregnant women and their partners via community events and personalised telephone contacts. This led to 40% of women taking up the offer of vaccination.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.