Lanchester 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.

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 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and they could not demonstrate that they effectively investigated or had recorded all safety events. Lessons were not learnt to continually identify and embed good practice.

We received concerns from patients, whistle-blowers, staff and the PPG that the practice was becoming unsafe due to a variety of issues, prior to our assessment. Feedback was that the provider did not listen to concerns.

We received conflicting information regarding the number of significant events recorded within the service, despite requesting this data multiple times during the assessment process.

We were told at our site visit by the provider that there had been issues with significant events. Some reported earlier in 2025 had not been reviewed until July 2025. We requested the policy governing significant events, this was not comprehensive. It said significant events would be discussed at weekly clinical meetings. We established during the assessment that these meetings had not been taking place weekly or at regular intervals and significant events were not standing agenda items when meetings did take place.

We asked for and received a summary of significant events for the last year after requesting it several times, it stated there were 27 of these recorded. There was no individual analysis of the 27 events, it was difficult to tell from actions recorded what these related to. This information was at odds with minutes of staff meetings where they were discussed. Collectively from the minutes it was recorded that there were at least 64 significant events recorded since February 2025. In looking at the minutes there was no evidence of investigation or outcome of these recorded. In some cases there was only a list of these, with no outcome.

There was therefore a risk to patient safety as the practice could not demonstrate all issues or near misses were investigated as significant events and there was learning identified to improve care. This meant that patients may be exposed to the risk of harm as the lack of an effective system to support reflection and shared learning from incidents increased the likelihood of the same incident happening again in the future.

We were unable to establish if there was a system to record and investigate complaints. We were given conflicting information regarding this during our assessment (see responsive domain below).

Therefore the practice did not learn from incidents and complaints to improve care for patients.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety.

At our assessment we identified concerns with workflow processes, particularly around document handling and clinical oversight of this.

We had received complaints from patients and whistle-blowers directly to CQC about poor management of test results prior to our assessment. We would normally check this information against significant events and complaints. We were unable to check this.

We received complaints from patients and whistleblowers that patients were being called by the provider with test results late at night. This was difficult for elderly patients as sometimes not enough time was given for them to get to the phone and they worried about the missed call which resulted in repeat calls to the surgery. The provider confirmed that this had happened due to the shortage of GPs.

The provider confirmed that no audit was conducted on the work of the administrative staff managing correspondence, where actions were taken by them on behalf of clinicians with overall responsibility. Staff confirmed this. The provider was unsure of the protocol used to determine which documents required GP review, this raised concerns about oversight and audit of this process

We carried out remote searches of clinical records as part of our assessment to check how the practice managed patients’ health. From this we identified previous delays in checking results, including blood, kidney function tests and tests for urinary tract infections (UTIs) and letters from hospital. Delays ranged from 2 weeks to 3 days. Some results were being checked on a Saturday. Pathology results should ideally be reviewed by a healthcare professional as soon as they are available. These were unnecessary delays to the reviewing of results and presented a risk to patients. We would have expected to see some of these raised as significant events.

We identified non-clinical staff filing ‘normal’ results. For example, for blood haemoglobin results. These should be reviewed by the GP who should interpret them in the context of the patient’s overall health and then discuss the findings with the patient.

We identified examples of where there were delays in actioning patient results and highlighted these to the provider. The provider attributed this to other staff, although we identified examples of where they had personally delayed actioning results.

They stated that a new process had recently been implemented to ensure all results are filed by the end of each day. However, during the site visit, staff reported to us results from up to three days prior remained unactioned on that day.

Staff shared with us that that tasks assigned by the provider were sometimes unclear or only partially addressed, requiring them to regularly seek clarification which sometimes resulted in delays to treatment.

There was no system in place to review or action patient safety or MHRA alerts. The provider told us the clinical pharmacist ran searches on the clinical system in response to the alerts. However the clinical pharmacist told us that they did not run the MHRA searches as part of their job plan. We identified from our remote clinical searches that there was no systematic reauditing to demonstrate ongoing compliance with patient safety alerts. Staff told us that currently no one at the practice had overall responsibility for safety alerts. The provider could not explain to us how they got to see the alerts; it was not clear if they took responsibility for acting against them or ensured they were seen by staff. This situation was blamed on staff absence, and no action had been taken to overcome these circumstances.

We had concerns that the processes and arrangements in place for safeguarding were not strong enough or given sufficient priority.

The practice had child and adult safeguarding policies in place. However, both polices were not dated with the last time they were updated. There were no local contact details for where to report any issues in the child safeguarding policy. This was of concern given that locum induction pack we were provided with was not comprehensive and locums worked on site unsupervised. Staff completed questionnaires for feedback provided by us. From these we received mixed answers regarding who they thought was the safeguarding lead at the practice.

We asked the provider about the child protection register. They were vague about this and said a member of staff who was at the time absent from work was responsible for the register. They told us there was a child protection meeting every month. At our site visit a member of staff showed us the child protection register and said they provided it to the child protection meetings. We were told by staff that the provider who was the safeguarding lead did not always attend the child protection meetings. We were shown minutes of safeguarding meetings for the 24 February and 21 July 2025. No other minutes could be found.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were concerned about the way clinical work was allocated, there was a lack of clinical supervision and audit and staff were at risk of being unable to recognise a deteriorating patient and action to take.

Many members of staff told us that they thought the practice was unsafe, they were not listened to regarding governance and staffing levels were unacceptable. They said workflow and appointment ledgers were constantly changed, which was challenging. Despite this being challenging they tried to offer a good service to patients.

In addition, there was no learning from incidents and complaints to identify risk and improve care for patients.

Emergency equipment was available and maintained.

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

We saw that contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits, other than a recent infection control audit had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We found training was up to date, for non-clinical staff. However, we were concerned that healthcare professionals did not have the training or support for the roles they were undertaking in seeing patients.

We saw the practice were not following their own clinical supervision policy, which was not comprehensive. There was no formal clinical supervision process, no audit of random case analysis recorded, including any audit of locums. It was reasonable to expect this as part of an effective clinical supervision process. The provider told us they relied on the clinicians’ bringing concerns to the Monday weekly meetings or staff knocking on the provider’s office door if they had questions. They were vague in answering about knowing the competencies of each nurse/Advanced Nurse Practitioner (ANP). We were very concerned about the oversight of clinical competencies and how it was decided which nurses had the competency and training to see which cohorts of patients, given they saw the majority of patients. We saw examples of poor consultations recorded by clinical staff. The provider agreed that clinical supervision needed to be better.

The clinical supervision policy stated there will be weekly clinical meetings. We failed to see any minutes of these. The minutes we saw were of practice meetings with limited clinical items recorded in the minutes.

We were concerned that a locum GP working at the practice may not know what is expected of them. They were left on site to work alone. The locum GP pack was inadequate. It did not cover key issues such as the safeguarding leads. There was no other protocol for locums working alone at the practice. We were told locum GPs were relied on for advice by staff.

These issues raised significant concerns about clinical safety, appropriate delegation, and the availability of qualified staff to support patient care.

We were told that staff appraisals were due the month of our assessment.

The governance surrounding recruitment was ineffective. We looked at 2 non-clinical staff and 3 locum nurse recruitment files in detail. From these we established there was no vaccination history for the 2 non-clinical staff or for 1 of the nurses. None of the nurses had an induction checklist, or data protection consent form. None of the nurses had references in their files. There were copies of nursing and midwifery council (NMC) registration, for the nurses, however these were not being regularly checked to ensure that they remained registered to practice. The certificates we saw were out of date.

The provider was the GP who was providing the majority of the clinical GP cover 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.

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 governance of infection control (IC) was not operated effectively. A health care assistant (HCA) had recently been made the IC lead and had received external training for this role. However, they had not been given time to implement any of their learning. We were provided with an IC policy prior to our assessment which was not dated, nor did it have any details of how often it would be reviewed. The policy lacked detail including the frequency of audits and processes were not stated. No audit program was set out. We spoke to staff about IC. The last IC audit was carried out on 13 September 2023. As the process was lacking in detail the practice could not be sure they were maintaining high standards of cleanliness and infection control.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning or the risks of medication explained to patients.

We received complaints from patients, the PPG and whistleblowers directly to CQC about prescribing errors. We were unable to draw any conclusions regarding this the provider was unable to provide us with the information we requested linked to significant events and complaints.

As part of our assessment we undertook remote clinical record searches, which included reviewing a sample of patient records, and we found examples of unsafe care. We saw that some medication reviews in patient records did not accurately reflect whether appropriate monitoring had taken place, in line with guidance. Medicines reviews to support patients were poor. There were examples of risks relating to prescribed medicines where it was not recorded that the risks of taking them had been explained to patients.

For example, we reviewed fifteen medication reviews. Overall, these were ineffective. They were being undertaken by nursing staff who were not qualified, not prescribers or were working outside of their scope of practice. They had missed key medications that needed review. This put patients at risk of unnecessary deterioration in their conditions.

We saw individual cases of patients where guidelines for medicines monitoring were not followed for the monitoring of chronic kidney disease, warfarin (blood thinning medication) and hormone replacement therapy, potentially leading to serious harm.

We identified 4 patients living with mental health conditions who were prescribed medication for anxiety or depression and had not received appropriate reviews. One patient for over several years and 3 patients over 3 years. Annual reviews are standard practice and should be part of routine medication monitoring. Without them, there is a risk that necessary changes such as reducing, increasing, or switching medication are missed, potentially compromising the patient’s safety and wellbeing.

We looked at patients who were prescribed a Direct Anticoagulant (DOAC) which is a type of medication prescribed to prevent and treat blood clots in a variety of conditions. We identified 10 patients who did not have creatinine clearance recorded. We saw examples of poor management of this. There was no recognition that following tests which highlighted patients’ renal function was sufficiently poor, that they needed a lower dose of DOAC or even to consider stopping the medication. There was evidence of this data being entered by an administrative member of staff without any further clinical oversight. We saw there was a lack of proper management of low anaemia levels.

The systems in place to manage safety alerts and medicines recalls was ineffective.

Emergency medicines and vaccines were stored and checked at appropriate times. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments