Lanchester Medical Centre

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

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.

The provider was in breach of Regulation 16 receiving and acting on complaints

The provider could not demonstrate they handled complaints or investigated them properly.

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

The service did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Our review of clinical records showed patients were not always supported to understand their condition or were involved in planning for their care needs. They were not always involved in decisions about their care.

For example, some clinical records showed no documented evidence of clinical reasoning, patient engagement, or consideration of treatment effectiveness.

There was ineffective management and oversight of long-term conditions, therefore the patients were not made aware of treatment or care choices.

For example, in the case of diabetic care we saw examples of poor oversight and control of care. Interventions were required and not carried out. Patient who were screened as being pre-diabetic were not being informed of this. Therefore, patients did not always have the choice of being at the centre of care and treatment choices as they were not made aware of the issues relating to their care.

There were shortfalls identified in how the service understood the health and care needs of patients, so care was not always joined-up, flexible or supportive of choice and continuity.

There were issues identified with the provision of care. For example, poor care for patients with asthma. Reviews were not always standard practice. Not enough care was given to question inhaler use and there were examples where guidelines were not followed.

There were issues with the flow of work, for example staff unclear on protocol, delays with checking results (bloods, liver function), tasks were written off or not responded to and there was no audit of this. Therefore, there was limited understanding of needs and poor continuity of care.

Lessons were not learnt from complaints and significant events to continually identify and embed good practice in giving good continuity of care.

The service did not always supply appropriate, accurate and up-to-date information to patients.

Communication with patients was sometimes poor. We identified delays in the processing of test results and hospital letters. Tasks which would result in communication with patients were sometimes delayed or written off.

We could not establish that complaints were dealt with, and a full response given to patients or that they were kept up to date with progress of their complaint.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard.

The service did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They did not involve people in decisions about their care or tell them what had changed as a result.

The practice could not demonstrate that they handled complaints or investigated them properly. We were supplied with changing information regarding the situation with these during the period of our assessment.

We asked for a number of complaints and a summary of complaints received within the last 12 months including evidence of actions taken, learning applied, and improvements made as a result. We were told this information was unavailable as a member of staff was absent. We were then told there were some complaints which could be viewed on our site visit.

At our site visit we were told there had been one verbal complaint which had been dealt with and there was no access to any formal complaints and responses. We saw a form called ‘have your say’ in the reception area. We asked if any of these had been completed. Originally, we were told no, then staff provided us with some of these which were found in a tray in the providers office. There were 23 of these presented to us; all were patients expressing their disappointment that a previous GP had left the practice. These had not been responded to. We asked again for complaints information as we knew the practice had received formal complaints from information we received from staff and patients; however, we were not provided with this information.

Following our site visit we asked that a summary of complaints be sent to us with a deadline. We then received a telephone call from a member of staff advising that complaints could not be accessed. We subsequently received a summary of complaints for June and July 2025, 4 in total. We were unable to view the investigation of these, or the responses made to the patients.

The practice complaints policy was provided to us. It was not dated or marked with when it should be reviewed. The practice’s "Responsible Person" was listed as the provider. The policy stated they were charged with ensuring complaints were handled in accordance with the regulations, that lessons learned are fully implemented, and that no complainant is discriminated against for making a complaint. The policy stated there would be an annual review of complaints. We were not provided with this information. The practice were therefore not following their complaints policy or NHS policy.

Staff told us that the provider had told them not to signpost patients to the practice’s complaints process. They told us formal complaints had been received about appointment availability.

The commission had received complaints from whistle-blowers, staff and patients about medication errors, clinical mistakes such as misdiagnosis and prescribing errors, with high risk of harm to patients in the previous 12 months, which we expected to see as complaints at our assessment.

The service did not make sure that people could access the care, support and treatment when they needed it.

Prior to our assessment we received concerns from patients, whistleblowers and the PPG highlighting limited access to GP appointments for patients. Most patients were being seen by Advanced Nurse Practitioners (ANPs). Additionally, there were reports of extended periods when no GP was physically present at the practice, or arriving late, raising further concerns about access to appropriate clinical oversight.

As part of our remote clinical searches, we reviewed the appointment ledger in response to the concerns and discussed this with the provider and staff.

We looked at a sample of 3 weeks for how often the provider who is the clinical lead was on site. There were locum GPs working there at the time. In the 3 different weeks they were working, they saw 4,5 and 7 patients face to face, in each week. The rest of the appointments being mainly administrative 2.5-minute queries or telephone queries. It appeared they were working remotely as the records were updated at 9-10pm despite appearing on the clinical system at around lunchtime.

We looked at GP cover in general in the appointment ledger. We saw examples of no GP cover at the practice or access to a GP on several occasions.

Examples included no GP on site on a Wednesday afternoon. The provider told us that this was an arrangement with the integrated care board (ICB), and patients could access a GP at the provider’s other surgery, which is not part of this contract. The ANP was working alone on a Wednesday afternoon on site. We have asked the ICB about this and they have confirmed this arrangement was not in place.

We saw examples of nursing staff working alone at the end of the day with no access to a GP. We saw examples of where a GP was not available at the surgery until 11am with no GP to supervise clinical staff before this.

Staff told us they regularly had to tell patients to ring NHS 111 or referred them to AE for urgent appointments as they could not offer them an appointment at the practice due to availability of appointments. They told us this happened on a regular basis and on the day of our site visit they had to redirect 3 patients to those services.

Staff said management had told them not to signpost patients to the practice’s complaints process. They told us formal complaints had been received about appointment availability.

Staff shared with us that there were frequent changes to appointment availability making it difficult to organise patient appointments consistently. They noted that clinic schedules were often altered due to the provider having other working commitments elsewhere, which added to the instability.

The provider was the GP who was providing the majority of the clinical GP cover at the time of our assessment, along with another salaried GP who did one clinical session per week. They told us a long-term locum had stopped working at the practice a few months earlier and it had been a struggle to cover the GP work at the practice. They were advertising for a salaried GP.

Staff and leaders did not actively listen to information about people who are most likely to experience inequality in experience or outcomes, or patients in general. This meant people’s care was not always tailored in response to this.

Feedback provided by people using the service, to us was mixed. Patients staff and the PPG gave us specific feedback that the provider did not listen to them and did not welcome feedback. We could not establish if the practice responded to and investigated complaints.

We were concerned that due to the standard of consultations and availability of GPs that patients were not always supported in their planning for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.