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.

At our last assessment, we rated this key question as inadequate. At this assessment, the rating has changed to requires improvement.

The provider was in breach of legal regulations in relation to receiving and acting upon complaints and good governance. We found the service did not always listen to concerns about safety and did not always fully investigate and learn from safety events.

This service scored 62 (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 always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always fully investigate and learn from safety events. Lessons were not always learnt to continually identify and embed good practice.

We found the service’s track record on complaints had led people wishing to raise their concerns to do so through other avenues, such as with the patient participation group, the Care Quality Commission (CQC) or the local Integrated Care Board (ICB). This was because they were not assured by the practice complaints processes, that they would be listened to and acted upon.

Although there were some improvements in the complaints system since our last inspection in July 2025, with complaints being recorded and action taken, the system was still not effective. There was a lack of insight into how to effectively investigate and learn from complaints. The provider reported a sharp increase in complaints immediately following publication of the CQC inspection report; however, in recent months, complaint numbers reduced. However, overall, we found complaints did not always inform quality improvement. They did not always fully establish the facts that led to the complaint or give a clear rationale of findings.

Representatives from the Patient Participation Group (PPG) told us the provider did not take complaints and significant events seriously enough and had not used them as a prompt to improve the service quality. They shared a significant number of examples where patients were dissatisfied with the response to their complaint.

Similarly, significant events we reviewed did not demonstrate the provider was learning and mitigating against the events reoccurring. We found significant events focused on remedial action rather than a proactive risk mitigation approach to learning from these events.

However, we did find the provider had acted upon the findings of the last CQC inspection. Some improvements were noted, particularly in relation to the care of people with long term conditions and monitoring of the safety and effectiveness of medicines. However, some areas, such as complaints handling and learning from incidents had shown some improvement but were not yet effective at supporting the practice to learn and improve. We were not assured the level of improvement was able to be continued or sustained, as it will take time to embed. Following our last inspection, we placed conditions on the provider. One of these was they must not carry on any regulated activity from Lanchester Medical Centre from 12 August 2025 until 14 November 2025. With the providers agreement, this was extended and they did not return to the practice until January 2026. During this period another provider stepped in to provide the service on behalf of Dr Kalra. Between January and March 2026, Dr Kalra had taken on increasing levels of responsibility for the provision of the service. At the time of our inspection on 21 and 23 April 2026, Dr Kalra had only resumed sole control for a few weeks.

The service had processes to work 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. While multidisciplinary meetings were arranged, they were not consistently attended by external healthcare professionals. Although these professionals were encouraged to share updates when unable to attend, this did not routinely happen. The practice had escalated these concerns through the local regional incident reporting system.

There were systems in place for processing information relating to new patients. However, staff told us there had been delays in processing these, due to staffing levels. The service worked with other providers to deliver shared care and when patients moved between services.

At our inspection in July 2025, we found the concerns with the process for managing workflow, particularly around document handling and clinical oversight of this. At this inspection, we found improvements had been made. A clear protocol had been implemented which identified responsibilities for management of workflow. There was an audit of this in place. Our clinical searches identified referrals and test results were now managed in a timely way.

We also found concerns in July 2025 with the system to review or action patient safety and (Medicines and Healthcare products Regulatory Agency) MHRA alerts. At this inspection, we found improvements had been made and responsibilities were now clear. Although we did not identify any concerns about how patient safety alerts had been managed through our clinical searches, we were not assured there was a system in place to reaudit on an ongoing basis to demonstrate ongoing compliance with historical patient safety alerts.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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 promptly and appropriately.

At the July 2025 CQC inspection, we identified concerns that the safeguarding policies were not dated, to confirm they had been recently reviewed. Also, they did not contain the local contact details available to guide staff on who to contact. Staff were unsure who the safeguarding lead was, and the lead did not always attend safeguarding meetings.

When we inspected in April 2026, we found safeguarding policies were in place and staff were appropriately trained in safeguarding procedures. They knew who the safeguarding lead was.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, the practice had experienced difficulty in effectively engaging with other health care professionals and organisations. Whilst invites were extended and requests for information made, other healthcare professionals did not attend or send information to inform safeguarding meetings. This meant information was not always being shared appropriately. The practice had escalated this through the regional incident recording system to highlight the concern to partner organisations and commissioners.

We found some improvements had been made to the way the service worked with people to understand and manage risks. They now provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

At our last CQC inspection, we found the service did not work well with people to understand and manage risks. For example, there were concerns about the way clinical work was allocated; there was a lack of clinical supervision and audit; there was a risk of staff being unable to recognise a deteriorating patient and the action to take. Staff raised concerns about staffing levels and there was no learning from incidents and complaints to identify risks and improve care for patients.

In April 2026, we found the practice had improved the way they allocated clinical work. There were improved arrangements in place to ensure patients’ health was monitored, any deterioration recognised and appropriate action taken in line with the National Institute for Health and Care Excellence (NICE). Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The provider had taken action to stabilise the clinical staffing arrangements. This included long term locum contracts for GPs, and directly employing nursing staff. They were still looking to appoint a salaried GP. The provider had also committed to working additional sessions to ensure cover. However, some staff raised concerns with us about the sustainability of this. We found no evidence to support this during our assessment. We considered more time was needed for the provider to demonstrate the sustainability and consistency of the staffing arrangements. The provider had introduced arrangements to ensure staff received adequate supervision.

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. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development.

In July 2025, we identified concerns with staffing levels; support, supervision and development for staff; and staff recruitment processes. In April 2026, we found the provider had taken steps to address these concerns. Clinical staffing levels had been stabilised with the addition of 2 longer term locum GPs and the recruitment of an advanced nurse practitioner, as well as additional sessions by the provider. However, we did receive information of concern following the site visit that alleged the provider was not maintaining their additional sessions as planned. We requested additional information, which showed only one instance over the 6-week period we reviewed, where a clinical session was cancelled by a locum GP due to unforeseen circumstances. Alternative emergency arrangements were put in place.

We found regular supervision sessions had been set up. An audit of clinical note keeping had also been undertaken to check on the clinical competence of staff. Safe recruitment practices were followed.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

In the July 2025 inspection, we found infection prevention and control governance and oversight was not well established or embedded. In April 2026, we found a new lead had been identified. Governance arrangements had been improved, but further time was needed to ensure these were fully embedded and effective. All staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

At our last CQC inspection, we found the service did not make sure that medicines and treatments were safe and met peoples’ needs. At this inspection (April 2026) we found the provider had made improvements. As part of our assessment, we undertook remote clinical record searches, which included reviewing a sample of patient records. This showed us within the practice, staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. We found they were appropriately monitoring medicines optimisation for disease-modifying antirheumatic drugs, medicines that slow or stop the progression of autoimmune and inflammatory diseases. Direct Anticoagulant (DOAC) medicines prescribed to prevent and treat blood clots in a variety of conditions were also monitored appropriately.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. 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.

Although the provider had effective systems to manage and respond to new safety alerts and medicine recalls, we were not assured there was a system in place to re-audit on an ongoing basis to demonstrate ongoing compliance with historical patient safety alerts.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.