Leylands Medical 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 requires improvement. At this assessment, the rating has changed to good.

This service scored 81 (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 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. Learning from incidents and complaints resulted in changes that improved care for others.

The practice always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

Leaders at the practice had dedicated time to review and improve processes within the practice to ensure information was available to staff, patients and other services. For example, the practice was involved in a pilot to auto-review blood test results alongside the clinical system provider. This practice had developed auto-review rules to enable results within normal parameters to be filed within the patient record, whilst ensuring any abnormal results were flagged for manual clinical review. This process reduced the amount of clinical time spent reviewing pathology results, resulting in increased capacity to provide direct patient care.

The practice had also reviewed and improved the system for arranging and managing test results. This ensured there was a structured approach, and all requests were raised in a consistent format with clearly detailed information. Test requests were then rated red (high-risk requests requiring booking action, confirmation of booking and further monitoring to ensure the patient had attended), amber (requiring booking action, confirmation of booking and monitoring to ensure patient attended for test) and green (routine requests that would result in no harm if the patient missed the test). This enabled administrators to easily access relevant information for accurate processing.

The practice had also introduced a process to ensure proactive communication with patients during transitions of care. This was rolled out across the musculoskeletal (MSK) service, long-term condition reviews, mental health transition review for 17 to 18 year olds and patients who had been referred under a 2 week wait urgent cancer referral.

For example, the practice had identified patients transitioning from child and adolescent mental health support into adult services as a high-risk point, where patients may experience difficulties due lack of continuity. To address this, the practice created a clinical system search to identify patients aged 17 to 18 who had been seen in the previous 12 months by services such as Child and Adolescent Mental Health Service (CAMHS), the secondary care psychiatry team and the early intervention in psychosis team. Historically, these records were reviewed by a GP partner to ensure all transitionary care was being co-ordinated appropriately and the patient engaged with this process. However, this had been further developed with the recruitment of an in-house mental health worker who proactively contacted patients to offer face to face support and ensure that transition planning was taking place, adult support arrangements were made clear, care was coordinated and the patient knew what support was available to them.

MSK journey updates provided patients with information including when their referral had been received, when the referral had been triaged and the outcome of the triage. Patients were also then informed what to expect next including any follow up communication of appointment arrangements.

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 were managed in a timely way.

The practice had systems in place to identify, record and act upon concerns. There were dedicated GP leads for safeguarding adults and children. All the staff we spoke with or received feedback from knew who the lead was and what steps they would take if they had any concerns.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. We noted that the nominated lead for safeguarding children was not clearly referenced in the safeguarding policy, however following our assessment, the provider confirmed that the policy had been updated to include this information.

The practice utilised the safeguarding node on the clinical system to identify vulnerable patients. Information stored within the safeguarding node was then available for other teams and organisations involved in the patients care.

The practice always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. All staff were aware of where this equipment was stored and of their role in the event of an emergency. We reviewed staff records and saw that staff had completed basic life support training. In addition, we heard how the nursing team had led a learning session with unannounced simulated emergencies that required the use of emergency equipment. This aimed to provide all staff with experience of using the equipment, improve collaborative working in emergency situations and ensure all staff members understood their role during a medical emergency.

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 practice had reviewed and improved the process for detection and management of sepsis. Leaders had implemented a structured sepsis risk assessment which was used during all routine care. The template supported clinicians to consider sepsis actively, stratify patients into low, moderate or high risk, and apply appropriate next-step advice including safety netting, urgent escalation, or emergency transfer where indicated. We saw that over the previous 12 months, 211 patients had been risk assessed for sepsis using the tool, with 19 escalated urgently to hospital.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During our site visit, we observed the premises to be clean and well maintained.

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. We noted that the Fire Risk Assessment for the main site (Leylands Medical Centre) had expired in February 2026, however the provider confirmed that this was scheduled to take place at the end of March 2026.

There was a business continuity plan in place which was monitored and reviewed.

The practice 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. Safe recruitment practices were followed.

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.

We found good systems and process in relation to infection, prevention and control (IPC) this included comprehensive cleaning schedules which outlined daily and weekly tasks.

The practice had a designated IPC lead who carried out regular audits of the premises. In addition, external audits were carried out.

We found good systems in place for sharps management; this was evidenced by a nurse responsibility sheet.

A Legionella risk assessment had been undertaken and control measures were in place which included water temperature checks being carried out at appropriate intervals.

The practice 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.

As part of this assessment, a Care Quality Commission (CQC) GP Specialist Advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. We found the practice had good systems in place to ensure patients prescribed disease-modifying antirheumatic drugs (DMARDs) and medicines requiring monitoring were appropriately managed. For example, clinical searches demonstrated that 100% of patients prescribed DMARDs had received appropriate monitoring. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw the practice was in line with or performed better than national averages in all 6 prescribing outcome areas. For example, the percentage of antibiotic items prescribed that are co-amoxiclav, Cephalosporins or Quinolones was 4.4% (expected 8%) and the average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) was 0.23 (expected 0.44).

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our review indicated a structured approach. We highlighted out of 5 patients reviewed, 3 patients required further review. We received written feedback from the practice that action had been taken to address this .

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.

Medicines 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.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.