Church Langley Medical Centre Also known as Dr M Kisenyi & Partners

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

At the last inspection, we rated the practice as Requires Improvement for providing effective services because there were examples of potential missed diagnoses of some long-term conditions. The management of people with long term conditions was not always in line with national guidance and the practice was unable to demonstrate that all staff had the skills, knowledge, and experience to carry out their roles. At this inspection, we continued to find examples of missed diagnoses of some long-term conditions and gaps in providing effective care; therefore, the practice continues to be rated Requires Improvement for providing effective services.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed complaints sent to CQC, including patient feedback as part of the inspection and we found mixed feedback regarding how their needs were assessed. Some patients described a positive experience when being assessed for minor surgery and eventual treatment. They described how the clinicians made them feel at ease and the dermatological procedure was explained clearly and patients praised the aftercare, including when further assessments were required following complications. However, some patients did not feel their needs were assessed effectively; for example, in relation to wound assessments and care.

Staff described how they undertook assessments and told us assessment needs were carried out at the point of registration, so patients who required extra support as well as presented with disabilities, were coded in their records and alerts placed on the screen. Health checks were carried out and vulnerable patients had access to home visits. Nursing staff told us they saw patients for chronic disease management using the relevant assessment tools then escalating to the GP as necessary, for medication changes and further reviews.

There were systems in place to assess patients’ needs using the appropriate clinical tools, including NHS health checks for patients aged 40-74 years. There were tools to identify patients living with moderate or severe frailty and mini memory tests were carried out to detect for possible signs of dementia. We saw the various, purpose built assessment tools they used to undertake their assessments and reviews. We viewed the various disease registers and how patient care was being managed, to support them in ensuring patient needs were being overseen correctly.

Whilst we saw evidence of assessing patient needs in some areas, we were not assured their systems were effective enough to prevent deterioration in all areas. For example, when we carried out clinical searches for potential missed diagnosis of long-term conditions, we found 3 patients as having a potential missed diagnosis of diabetes. However, when we reviewed their records we saw they had been appropriately coded and there were no issues with their monitoring or evidence of any potential patient harm. When we carried out our clinical searches, we found 55 out of 1279 patients on the asthma register had been prescribed 2 or more rescue steroids in the past year due to an exacerbation of their condition. When we reviewed 5 of the 55 records, we found 2 of these patients had not received an adequate assessment at the time of prescribing rescue steroids. None of these 5 patients had been followed up to check response to treatment a week after being prescribed rescue steroids and this placed them at risk of deterioration. The gaps in adequate assessments were consistent with complaints we received from patients. For example, in one case, ongoing cough symptoms were inadequately assessed so this led to an emergency hospital admission a week later with a life-threatening condition. CQC received up to 7 other cases relating to a lack of adequate assessments leading to deterioration in a patient’s condition or hospital admissions.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. Some patients described an overall positive experience and told us they were called for their annual reviews. This was consistent with some of the verified NHS reviews where some patients fed back that they found arranging their annual reviews easy. However, feedback sent to CQC highlighted issues with evidence-based care where some patients felt the management of their chronic conditions was not satisfactory and in some cases, led to adverse issues.

Clinicians told us they followed national guidance such as NICE guidelines and nursing staff told us they also followed their NMC guidelines, relevant policies and legislation in relation to patient care and supporting decision making. Leaders told us national guidelines were discussed in clinical meetings and staff had access to locality and wider based external training on the latest guidance. Leaders told us they remained one of the high achievers in long-term condition management. They told us they had a monthly review of missed diagnoses of CKD and diabetes using CQC searches on their clinical system. Clinicians described the asthma Florey system to assess who required reviews and nursing staff were responsible for reviewing their asthma and COPD patients, including assessing their inhaler techniques. Clinicians also told us missed diagnosis was accurately coded and followed up for appropriate review with? patients. They increased their efficiency with regards to long term reviews by implementing a one stop shop for the patient instead of them having to attend multiple appointments.

The practice had systems and processes to keep clinicians up to date with current evidence-based practice and this was supported by the clinical supervision policy in place. We saw evidence of diabetes learning sessions organised by the integrated care board (ICB) learning hub, providing key updates and guidance. We viewed multidisciplinary team meetings where complex patients were discussed and care was co-ordinated with other members of the team. There were also systems in place to discuss national guidelines in clinical meetings; however, we were not assured these discussions were captured effectively or consistently, and shared with all relevant staff. For example, we saw clear evidence of national guidelines for statins and diabetes being shared in nurse meetings; however, the August and September 2024 clinical meeting records did not show clear discussions around national guidance. There records also didn’t demonstrate any audit trails of how those unable to attend the meetings were made aware of guidance updates.

Our clinical records searches showed generally patients' conditions were managed in line with guidance; however, we saw examples of overdue chronic disease monitoring. For example, we found 2 out of 329 patients diagnosed with hypothyroidism were overdue their monitoring and had not been short scripted when invited and not complied as per national guidance. We also found that 1 out of 38 patients diagnosed with chronic kidney disease (CKD) stage 4 or 5 had not received recent blood test monitoring in their records. Overdue monitoring placed patients at risk of deterioration. However, we also found evidence of effective care; for example, we reviewed 5 of the 110 records for patients diagnosed with diabetes and with high average blood sugar levels and found their monitoring was up to date and carried out as per national guidance. We also found a sample of 5 of the 148 patients prescribed SGLT-2 inhibitors had been given advice regarding ketoacidosis or Fournier’s gangrene since starting the medicine, as per national guidance.

Online community groups included commending teamwork at the practice. However, this feedback was not consistent, one patient told us they observed staff who were worried about the potential consequences of submitting feedback to the management and they also told us that some staff did not know how to follow practice policies. The Patient Participation Group (PPG) told us on the day of inspection that they felt the way the practice worked with them could improve particularly around communication and transparency when sharing information.

Staff told us they worked well together as a team and with other organisations to deliver effective care and treatment. Nursing staff told us they worked well with the duty GPs who supported their day-to-day practice by assisting them if they required GP advice on their patients. The GPs would also come and assess the patient for them if it was beyond their scope of practice and supported them with the next steps of care. Some staff felt teamwork could be improved; for example, they told us on occasion there was a divide between reception and admin teams and this could be improved if each of the teams had insight into how the other team worked, so they could help patients with quick win questions, such as referrals.

Feedback received from the HWEICB was that the practice engaged well with the Pharmacy Medicines Optimisation Team (PMOT) and sought other necessary support from the ICB when required. They had also sought assurances from the practice following a spate of whistleblowing concerns raised with them prior to the inspection.

The practice was the local referral centre for minor surgery as the lead GP had a diploma in dermatology. The practice worked together in partnership with their local citizens advice bureau who provided drop-in outreach sessions every other Tuesday, to assist patients with their advice issues as part of their social prescription. Patients also had access to the social prescriber in 20–30-minute appointments.We saw how staff worked together through their monthly practice newsletters and on inspection, we observed staff working well together. However, we did observe some staff were not happy in their roles and felt relationships in the practice amongst the different teams could be improved. We saw multidisciplinary team minutes of meetings, held between August and October 2024 and co-ordinated team work to meet the needs of complex patients. These minutes showed case discussions and relevant updates were shared amongst the different team members such as mental health team, social worker, community matron and end of life nurse. We also saw evidence of clinical, reception and nursing team meetings.

Patients who provided us with feedback told us how staff supported them to live healthier lives and they found the staff, namely the social prescribers very helpful.

Staff told us they promoted health and provided diet and lifestyle advice following practice policies and protocols, for example cholesterol advice, advice on prediabetes to try and prevent future health issues. Patients were promoted to participate in their own care plans. Patients also had access to social prescribers. Staff who carried out weight checks on patients did not feel there were enough treatment options for patients with a high BMI. Nursing staff took part in the ‘wear it pink’ breast cancer campaign and praised the practice for supporting the fund-raising event, alongside raising awareness amongst staff and patients.

We saw evidence that where possible, the practice supported people to manage their health and wellbeing so they could maximise their independence, choice and control. There was a care co-ordinator for health checks and weight management, also responsible for referring patients on via the relevant referral pathway. People living with a long-term health condition underwent regular monitoring. They were referred or signposted to local support services for information, education, advice and support linked to their needs. For example, diabetes patients were signposted to the education structured programmes and patients were also offered dietary advice and smoking cessation. Pre-diabetes patients were invited to regular reviews which included diabetic panel bloods and foot checks. The practice could refer patients to it’s website for health and information section including ways to keep healthy and a live well section which had information relating to sleep and tiredness and the steps to mental wellbeing. The practice met their cervical screening intake target which had increased from 65% to 81% by increasing nurse availability and issuing invitations on pink paper and in various languages, as well as a social media drive to improve uptake.

People did not always feel their care and support was planned proactively in partnership with them. Some patients reported that their conditions deteriorated following encounters with the practice where their symptoms were missed, whilst some patients felt involved in their care and were happy with the outcomes of appointments.

Leaders told us there was a GP lead for patients with learning disabilities and a GP assistant co-ordinated their annual review recall. Staff told us learning disability health checks were booked with the patient or designated family member depending on preference. Blood tests were booked at the practice with extended appointments for ease and follow ups were booked according to patient’s preferred time of day and other reasonable adjustments were recorded on their front screen. Family members attending with patients were accommodated to provide space and time to suit. GPs told us all learning disability reviews were completed in the last year and they carried out cancer care reviews and there was a push to carry out initial and annual reviews. Nursing staff told us they carried out wound care related audits.

National priorities and initiatives were used to improve the health of patients. Reasonable adjustments were in place for patients that required them. We saw evidence of health promotion campaigns, such as NHS Health checks and 2 staff had been trained to undertake health checks and 2 other staff had also received smoking cessation training to be able to deliver it onsite. Hypertension posters were available for patients and additional appointments were added for health checks. The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements. They also reviewed unplanned admissions to hospital. However, we were not assured adequate action was taken to prevent the number of missed diagnosis concerns being raised by patients. For example, one patient told us they had not been informed by the practice that they had a particular disease until they moved GPs, whilst another patient told us about having surgery for a condition which had been missed at an appointment for pain.

People were supported to attend annual health checks, screening and primary care services. Our clinical records search showed 35 out of 37 patients diagnosed with learning disabilities had a health check in the past year. When we reviewed 5 out of 110 patients diagnosed with diabetes, we found all 5 patients had received their diabetes annual review. The cancer prevention data for 2022/23 showed that 68% of patients aged between 53-70 years had received breast cancer screening and this was comparable to the national average of 67%. Data also showed 70% of patients between 60 to 74 years of age had received bowel cancer screening and this was comparable to the national average of 72%. We saw evidence of clinical audits; for example, appointment and antibiotic audits, baby milk and minor op audits.

Some patients shared that they felt the practice was dismissive and they did not receive appropriate support to make decisions. We saw examples of concerns where blood tests were taken from patients without their consent and no effort had been made to ensure the patients had fully understood the purpose of taking their bloods. Some shared their positive feedback of how clinicians had sought their consent to have a colleague observe their appointment.

Staff told us they obtained consent to care and treatment in line with legislation and guidance. They were aware of the requirements to gain patient consent to care and treatment and had been provided with training where relevant to their role, including applying Gillick competencies to decision making. Nursing staff told us they considered local policies and wider legislation including the Mental Capacity Act and the mental health code of practice, along with NMC guidelines in order to make sure consent and respect were followed for all cohorts attending.

The practice had policies and procedures for obtaining consent to care and treatment, which reflected current legislation and guidance. When we reviewed their consent processes, we found Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were not always recorded in line with relevant legislation. Mental Capacity Act (MCA) and DNACPR policies were up to date but , there were gaps around consent documentation where they were not always documented fully as required by the forms. For example, 2 minor surgery consent forms did not have all relevant areas fully completed and were left blank. In a DNACPR form, both the GP completing the form and endorsing senior clinician’s signatures were not recorded and the indefinite decision section was left blank. Therefore, the practice could not demonstrate they were always following guidance to show patients had been supported around informed decision making relating to their treatment and care.Staff were all up to date with consent training and Mental Capacity Act training, although some staff there were coming to their update training annual due date within the next month. Where patients did not want to be resuscitated the practice documented those discussions had taken place with the patient; however, gaps were identified in the documentation; for example, having appropriately signed authorisation.