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

There was an open culture, staff told us that safety was a top priority. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues.
There was a system to record, investigate and monitor complaints for trends. When things went wrong, the service learned from this and made changes. For example, following a complaint the lone working policy and process was revised. The PPG also fed back to us where they have raised concerns, the service acted upon and learned from these.
The service had processes for significant event reporting and analysis. Staff were able to give us examples of how the service had made changes to a procedure following an event relating to missed diagnosis.
Learning from incidents and complaints resulted in changes that improved care for others. One member of staff told us ‘everything gets reported’ highlighting the service’s commitment to being open to receiving and acting upon identified issues.
 

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. This included the sharing of systems with external teams to allow for seamless transitions in services.
There were systems in place for processing information relating to new patients and this was completed in a timely way.
Referrals were managed in a timely way and were monitored for completion. There were systems for monitoring and managing suspected cancer referrals.
The service had enough appointments for people that required an urgent appointment. However, we found that the service had a longer wait for routine appointments. In January 2026, it was noted that there was an approximate 12 week wait for routine appointments. However, when we undertook the site visit, this wait had improved and had reduced to approximately 7 weeks. The service was aware of this and to mitigate risks people were safety netted by being given advice on what to do should their condition got worse.
Referrals and test results were managed in a timely way, with each GP managing their own test results.
Staff had the equipment they required to carry out their role.
 

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. 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.
Staff were aware of safeguarding policies and were appropriately trained in safeguarding procedures. They were aware of who the safeguarding leads were within the service. Clinicians attended local authority risk management meetings.
Staff were able to give examples of cases where safeguarding alerts had been raised to the local authority resulting in a multi-professional approach to keep a child safe.
The service maintained a list of vulnerable people, both of adult and children age and acted on concerns working in partnership with other organisations.
A review of safeguarding records showed that alerts were appropriately placed on patient records and their household family members.
 

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 what action to take. There were informative posters on display to highlight the symptoms of serious conditions such as a stroke or sepsis.
People were advised on risks related to their condition and actions to take if their condition deteriorated. Staff reported that it was easy to speak to a GP if they needed clinical advice.
Emergency equipment was available and maintained. However, we noted during the site visit, an item of emergency equipment was out of date, this was rectified on the day.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Contracts were in place to ensure the premises were maintained and we found clinical waste was stored securely. Health and safety risk assessments and audits had been undertaken. Risks had been identified had addressed. There was a business continuity plan in place which was monitored and reviewed.
The service was accessible for people who use mobility aids such as scooters and wheelchairs and there were designated disabled parking bays. We found walkways to be clear with handrails in place. Toilets and baby changing facilities were available and were observed as clean.
There were policies and procedures for fire safety and appropriate and checks of fire equipment were recorded. The service had trained fire marshals and staff knew who they were.
 

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.
There were a range of clinical and non-clinical roles within the service, including staff with specialisms such as a respiratory nurse and diabetic nurse. The service ia part of a primary care network (PCN), a group of GP services that work together with other local health and social care organisations to provide integrated services for their communities.. The PCN provided roles such as pharmacy technicians, physiotherapists and health coaches to support the provision of additional services.
Safe recruitment practices were followed. We reviewed 5 recruitment files and found appropriate recruitment checks had been carried out, including obtaining references and a disclosure and barring service (DBS) checks. ( a DBS check enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work).
A centralised system was used to record and monitor staff training. Staff told us how the system ‘’alerts you if training or your appraisal is due’’.
Staff training was up-to-date, with learning needs and development of staff was managed appropriately.
Staff told us that there were opportunities to develop in areas such as leadership and they had time complete their continued professional development (CPD).
A staff member told us that following their appraisal, they were entered onto the practice manager development programme to expand their skill set.
The service closed for half a day per month to enable protected learning time for staff. They told us during these closures, additional training took place as well as other activities such as mindfulness and meditation.
Staff told us that they felt supported in their role and received clinical supervision. We found that appraisals had been scheduled for staff, including GP’s and this was monitored through the centralised system. We found that supervision was not recorded and the service was in the process to revising their process to ensure it is recorded.
 

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
The practice had a designated infection, prevention and control (IPC) lead and staff knew who this was. Staff had completed relevant training. Cleaning schedules were in place and followed. Audits of cleanliness were completed and the outcomes shared with the service for monitoring.
Audits such as environmental and handwashing, were completed. However, where staff had not met the required standard, we found no information to show how this had been followed up.
The service held records of staff immunisations. There were systems for waste and clinical specimen management. However, we found that the specimen deposit box posed a risk of infection due to contents not being stored securely, potentially posing a risk to people using the service. We also found that in non-pedal bins were in place in some toilets, posing an infection risk.
We found that some clinical equipment had not been cleaned with the appropriate cleaning product required for safe infection prevention and control. The service took action to address this, implementing additional records to demonstrate equipment is being cleaned with the appropriate products.
 

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, such as in reviews of peoples’ prescribed medicines.
Staff received regular training and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.
Medicines including controlled drugs and vaccines were stored securely with stock checks taking place and were stored at appropriate temperatures.
Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.
As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor.
Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, they were not always effective as our clinical searches identified in 4 of 5 medicines reviewed during our clinical searches. We found that monitoring did not always take place for people who were prescribed medicine for heart failure, the service responded to this by arranging appointments for people in this group.

The searches also found that 54% of patients on gabapentinoids (a medicine that is used to treat conditions such as neuropathic pain ) had not had a medication review in the past 12 months. A review of 5 of these records for people prescribed this medicine showed that 4 of 5 people had not had a review in at least the past 2 years.
The service had processes for the management of safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA), and staff told us these were circulated to teams by the prescribing lead.
There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. This included non-medical prescribing staff who received clinical oversight and audits of their prescribing.
We reviewed the services patient group directions (a legally recognised written instruction that allows registered clinicians to supply and/or administer specified prescription only medicines to groups of patients without the need for an individual prescription). We found that these had been appropriately authorised.