Lanchester 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.

This is the first inspection for this service since the provider registered the service with CQC. This key question has been rated as inadequate.

The provider was in breach of Regulation 12 in relation to the provision of safe care and treatment. Issues identified included clinical concerns around inadequate management of medicines and long-term conditions. Safe access to appointments. There was no system for patient safety and Medicines and Healthcare products Regulatory Agency (MHRA) alerts. They were not following National Institute for Health and Care Excellence (NICE) guidance. There was poor management of workflow of test results, hospital letters and tasks written off or not responded to.

This led to the CQC taking enforcement action and imposing conditions on the provider. Further details can be found in the overall service commentary earlier in this report.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We identified significant risk of future harm to patients due to ineffective management and oversight of long-term conditions. The clinical governance arrangements lacked the necessary oversight and effectiveness, which evidenced the potential for patient harm. If this poor standard of clinical care and oversight of long-term conditions were allowed to continue, it would lead to an acceleration of these conditions and a reduction in the patients’ quality of life.

We received feedback from patients of clinical concerns following consultations and we identified poor care from our clinical searches. Concerns were raised with us of poor process regarding the management of test results and medicines. However, we received feedback from some patients using the service which was positive.

We found evidence that national and local guidance, such as NICE guidance was not followed.

We found evidence that a significant number of patients were experiencing poor diabetic oversight and control. Treatment escalation was inconsistent and, in many cases, ineffective. Clinicians had not consistently recognised when additional intervention was required and there was insufficient attention to associated cardiovascular risk factors including elevated cholesterol levels. This would warrant consideration of statin therapy and blood pressure readings exceeding the levels usually warranting treatment of patients with diabetes. These issues had not been reliably identified or addressed with treatment from the clinical team.

Notably some patients had already presented with complications such as retinopathy or leg ulcers indicating end organ damage. Despite this the care provided has been suboptimal. Staff reported to us that HBA1C results were either not actioned or, when actioned, not always managed appropriately. This is a test which measures a patient’s average blood glucose (sugar) levels over the past two to three monthsand is a key indicator for diagnosing and monitoring diabetes and pre-diabetes.Additionally, the PPG raised concerns about the quality of diabetic care at the practice, noting that patients identified as pre-diabetic following blood tests were not consistently informed of their diagnosis.

We found examples of poor care in relation to the management of patients with asthma. The clinical records we reviewed showed that annual reviews were not standard practice. Some patients were only reviewed when they were ill. It would be expected atleast an annual review would be standard practice and would form part of an annual medication review. This put the patients at avoidable increased risk of hospitalisation or severe asthma attack.

Not enough care was given to question adherence to preventer treatments or to follow guidance. Exacerbation of asthma was not always triggering an asthma review. There were instances where guidelines were not being followed, accepting too readily a patient’s preference to be taking a reliever without follow-up or assessment of their condition. There was no clear prescribing policy for the issue of relievers.

We saw other examples of consultations for various conditions/illness where examinations were not carried out in line with guidance or standard practice or sometimes not documented that an examination took place. Staff told us that patients had complained to them that they had not been examined or looked at during their consultation. This was ineffective management of care.

The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards. Clinical records we saw did not demonstrate that care was provided in line with current guidance including NICE guidance.

The provider told us NICE guidance was available on the clinical system. They said guidelines were discussed in the practice meeting. They told us they did not have any subscription for alerts for themself. Our clinical searches have showed that NICE guidance was not followed in some cases, therefore raising the risk of patient safety. In the practice meeting minutes dated 28 July 2025 there was an instruction for all clinical staff to subscribe to NICE guidelines.

We asked for examples of clinical audits. The audits provided were not complete cycles so did not demonstrate any improvement to patient care or outcomes and it was not clear why each audit had been chosen or completed.

The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We saw that staff did not have access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. For example clinical supervision and up to date guidance.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We saw examples of where staff did not have the skills to identify risks to patients’ health, including patients with or at risk of developing a long-term condition and those with caring responsibilities. Staff told us they supported national priorities and initiatives to improve population health, including stopping smoking.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

From the clinical notes we reviewed, we found that people who used the service did not always experience positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

For example, we saw examples of where patients were over treated with antibiotics. In some cases, there were other first line treatments which could have been explored. These were not being discussed with patients. Where guidelines would suggest there would need to be good reasons to use antibiotics, these were not recorded. Where antibiotics are not the recommended treatment, risks to patients are increased, including sepsis and antibiotic resistance.

The practice met national targets for screening and immunisations. The latest verified data held from 2024 showed the % of persons eligible for cervical cancer screening who were screened adequately was 84% compared to expected uptake of 80%.

The 4 indicators for childhood immunisations we held from 2024 were all above the World Health Organisation (WHO) recommended coverage of 95%. For example, the percentage of children aged 5 who have received immunisation for measles, mumps and rubella (two doses of MMR) was 97.4%.

The service 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 recorded.