Lepton & Kirkheaton Surgeries

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 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.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

There were some processes in place for premises maintenance and for health and safety risk management, such as equipment calibration, portable appliance testing, and gas safety checks. However, some premises records were incomplete or unavailable at the time of the site visit. This included a recent gap of approximately 3 months in records including emergency lighting checks and water temperature testing for Legionella risk management. The service advised that this period coincided with a change in staffing responsibilities, and that recording had now resumed appropriately under the new arrangements. External Legionella risk assessments had not been carried out, however we saw that the service had taken steps to arrange for these to be completed soon after the assessment, as well as putting together a new policy to cover water systems management. In addition, there was only 1 record of a fire evacuation drill at each site, which was from October 2025. In mitigation of this we saw evidence of regular fire alarm servicing, fire extinguisher maintenance, and fire risk assessments, at both sites.

The service had a business continuity plan which outlined how the service should continue to operate in the event of a disruption.

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 service employed a range of clinical and non-clinical roles, which included GPs, nurses, and pharmacists.

The service carried out regular clinical supervision sessions for all non-medical clinical staff, which included audits of prescribing for relevant staff. Staff told us that guidance and support was readily available, and that regular meetings provided opportunities to discuss individual cases and seek advice. Staff also received regular appraisals and one-to-one meetings.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of staff immunisation status, and a criminal records check. However, there were a small number of recruitment documents that the service could not locate.

Staff were largely up to date with mandatory training. We noted that a few staff members had completed a large proportion of their required training after the assessment had been announced, and 1 member of staff had not completed safeguarding training to the appropriate level, however this training was completed promptly after the assessment.

The service did not always appropriately assess or manage the risk of infection.

Whereas the main site was found to be clean, we found high-level dust in clinical rooms at the branch site. Cleaning schedules were available, however we were told that cleaning records had not been completed by the external cleaning company for a significant period. The service explained that it had already recognised that cleaning standards were not meeting expectations prior to the assessment, and had appointed a new cleaning company starting in July 2026.

An Infection Prevention and Control (IPC) lead was in place, and annual internal audits were conducted. The majority of actions identified through these audits had been completed, however a small number of actions remained outstanding. The associated due dates for these actions had only just passed, however at the time of the assessment there was no evidence of progress made on these outstanding actions. The service told us that there were plans to introduce external audits to strengthen oversight and improve compliance.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.