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

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At the last inspection, we rated the practice Inadequate for providing well-led services because governance and management arrangements were not effective, for example cold chain processes and the management of emergency equipment were ineffective. There were gaps in the systems and processes for managing risk. • The practice had a vision and strategy; however, not all staff aware of this. The practice culture did not always effectively support the delivery of high-quality sustainable care. There was a lack of engagement with patients about their experience of the practice. At this inspection, we found some improvement had been made to address the gaps found at the last inspection; however, there were still gaps in how the practice was led, so we rated the practice as Requires Improvement.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some of the staff knew the mission statement of the practice, which was to provide professional, accessible, high quality, comprehensive healthcare services that inspired confidence in their patients and community. Staff could also describe the culture of the practice and some described it as generally good, whilst some felt improvements could be made to the shared direction and culture. Some felt they were not involved in developing the strategic planning; for example, the mission statement, vision and values of the practice, whilst those aware of the mission statement told us they suggested to the leaders that they could make the mission statement more catchy and shorter to become more memorable and digestible for people. Some teams had a good bond with helpful and supportive peers. Leaders recognised they wanted their mission and values to be more inclusive, more representative of patients and staff, they wanted their patient engagement to improve and their staff to feel included. They told us staff were the face and voice of the practice and in order to develop their shared direction and values, they had to stand by them and be proud to work at the practice. They told us they enjoyed coming to work and found whilst others did not feel this way but rather felt isolated. Some of the staff had described the culture as an ‘us vs them’ culture and were not made to feel valued. Staff also spoke of the challenges they faced since their last CQC inspection and told us they were working on making on-going improvements. They told us how this had an initial impact on staff retention and recruitment.

The practice created a risk register and were working through the areas highlighted in this register. Staff had access to all the practice index policies when needed. The practice mission, vision and values were displayed on the practice website. We reviewed the practice mission statement. We viewed a suite of policies which were now available on the new Practice Index tool, which offered read receipts and fully auditable trails. We observed how leaders invested in staff events in order to improve the culture and relationships within the practice.Leaders recognised improvements since the last inspection were still a work in progress and they were receptive to the provided by the inspection team.

We received significantly mixed feedback from staff regarding leadership. Some of the staff found the team leaders and managers visible and approachable and felt they could ask them anything when needed. They enjoyed the staff social events provided by the practice and credited them for improving relations in the practice. Other staff told us how the provider was supporting them through their professional development and when experiencing significant life changes and other staff described the culture as one of a family. Equally, some of the staff felt although nursing leadership and certain team leaders were helpful, the practice management was not so visible or supportive, found them hard to approach. Some staff members felt unsupported with some describing they were made to feel worthless and others felt secluded.

Although leaders understood the challenges to quality and sustainability, we were not assured there was a consistent culture to deliver high quality sustainable care. When patients were affected by things that went wrong, they were not always given an apology and informed of any resulting action to prevent recurrence, as highlighted in the significant events and patient feedback. Staff feedback showed staff did not always feel supported by the leadership especially when raising concerns. This was consistent with patient feedbackregarding their observations of staff interactions. Some patients told us they observed some staff reluctant to raise a query with management due to fear of being shouted at because this had happened in the past.

The provider recognised improvements since the last inspection were still a work in progress and they were receptive to the provided by the inspection team. There was a leadership development programme, including a succession plan. We saw clear evidence of this when their nursing staff was promoted to a lead nurse role as well as the support in place for staff as part of their professional development. We saw evidence of how leaders historically acted to safeguard both patients and staff when faced with employees who placed people at risk of harm. We saw evidence of 2 significant cases where external parties were involved in order to safeguard staff and the public. We also saw evidence of when the practice followed their disciplinary procedures for staff not performing as per the required standards.

Prior to the inspection, CQC sent all staff working at the practice individual staff feedback forms. The practice had a diverse workforce, so these feedback forms were confidential and offered staff an opportunity to feedback their experiences of working at the practice, as well as to hear their individual voices in a way we would not normally have previously done on inspection due to time constraints. Of the 24 feedback forms sent out, we received back 13 staff responses, all of which here happy to provide feedback except for one member of staff who had not seen the benefit of doing so. Staff gave us greater insight into their roles, including their understanding of the policies and procedures at the practice. Staff were also open and transparent about the practice and about any concerns they had. We also carried out staff interviews as part of the remote and onsite inspections on 7 and 11 November 2024. We spoke to a wide range of staff from front line reception staff, admin and clinical staff.

We received mixed feedback from staff regarding speaking up. Some staff told us they were encouraged to speak up and some we spoke to told us they were not afraid to report a mistake as the practice had a no blame culture and they learnt from errors and guidance. Staff also told us they had access to a suggestion box to senior management for staff to provide feedback and they felt free to speak up. However, not all staff felt this way as some staff felt they could not speak up without retribution. When we spoke to the leaders, they told us they had an open-door policy and staff could knock anytime but this was not reflected in feedback we received from both staff and patients. They discussed how historically when they had issues with staff and how this impacted them as a practice.

There were processes in place for staff to speak out; however, following staff feedback, we were not assured all staff felt they could speak up without fear of retribution. There was a freedom to speak up policy and there was a Freedom to Speak up Guardian and staff told us they were aware of them. However, most of the staff provided a guardian that was inconsistent with the designated guardian assigned to the practice. For example, most of the staff told us their Freedom to speak up guardian was a practice manager at a neighbouring practice; however, the designated guardian was based at the Herts and West Essex Integrated Care Board (HWEICB). The whistleblowing policy was embedded within the staff handbook.

A few staff raised several concerns with CQC and the HWEICB relating to various issues. The practice was provided with an opportunity to address the concerns and themes around the issues raised with them, mainly those relating to patient safety. Assurances were sought from the practice that all staff felt free to speak up and all concerns they had would be fairly investigated. The practice was responsive to all requests for information and provided evidence of how they had addressed the staff concern themes raised with CQC, although we were still not assured all staff concerns had been addressed. Improvement to how staff feeling free to speak up will continue to be monitored and reviewed at the next inspection.

We received significantly different feedback from staff when we sought their views using the confidential feedback forms, as well as speaking to individual staff on both days of inspection. Feedback from staff was mixed in relation to workforce equality and fair treatment. Staff told us the practice had a friendly, positive and supportive team, as well as an open culture that promoted equality and diversity in their work activities and behaviours. However, some staff were not happy and described negative experiences of their employment. Some staff felt the senior management team did not take action to intervene and support staff when they heard non-clinical staff being screamed and shouted at by aggressive patients which created an awkward atmosphere for staff. The provider told us they had survey monkey feedback planned for staff and the Patient Participation Group (PPG).

The practice had a diverse workforce. We saw that staff were offered reasonable adjustments where required; for example, one staff member could work from home following a recent medical intervention. The practice staff had access to Occupational Health and there were systems in place to refer them. They had a recruitment policy and a comprehensive staff handbook with access to many other policies and practice procedures, such as the bullying and harassment policy and HR information . All staff, including non-practice and locum staff were included in staff social events which was an open invitation via the practice newsletter and we saw that the provider tried to accommodate all staff members; however, this did not improve all staff morale and we also found that in some cases, behaviours inconsistent with their values and visions had been displayed by certain people towards others.

Some of the staff told us they were provided with enough guidance, written procedures and policies to perform their role accessible on their practice index. Some staff told us they loved their roles and responsibilities that came with their job and felt valued as team members. However, some staff told us they had not received training for their role and would not choose that role again as a result. Some staff appreciated the additional workload on clinical staff since the Covid-19 pandemic, especially when patients were waiting for their secondary care appointments.

There were gaps in governance structure which was consistent with patient and staff feedback. We also found gaps in consent documentation as well as where information relating to the practice was lost following IT company move. This documentation included partnership meetings, payroll documents and historic pay uplift data. Although the provider told us they were not moving IT company again, we were not assured that enough action had been taken to prevent this happening again. The practice had an organisation structure chart; however, it was not up to date as it omitted one member of the ARRS clinicians. Gaps were also found in governance systems such as sharing and learning culture, medicines management, significant events, legionella assessments, complaints and listening to people. Not all staff were aware of the business continuity plan.

The provider recognised the financial challenges that affected their ability to recruit and retain staff to posts due to increased pension contributions and minimum wage following the October 2024 budget. They had also been affected by the Carr hill formula budget whereby there was a demand for young families which was their largest demographic; however, they were the lowest funded provider in the country with a funding of £72 per patient, lower than the national average of £115, so they had to be a lot more efficient with the underfunding and had an impact on their sustainability. However, they were also able to raise extra income through their minor surgery and joint injections and being a teaching practice. They told us they would continue to challenge this formula. The practice was also a Tier 2 sponsor for staff on a visa scheme but also recognised that people mostly preferred working in London due to better pay conditions. The practice also saw an increased demand of up to 2,000 patients following the closure of a local practice. There were also new housing developments being built in their local area which could see further increase of their list size.The HWEICB had confirmed that the practice was affected by chronic underfunding which was a central not local issue and affected their weighted population.

The practice re-established the Patient Participation Group (PPG) following the covid-19 pandemic. They held 4 meetings with the practice since January 2024 with 15 members in attendance. The members of the PPG expressed their desires for better engagement with the practice. They told us there was no chairperson and meetings were short notice with just 24-hour's notice and there was no mission statement, purpose, agenda or actions. They also wanted to work in partnership with the practice for action plan updates from the last inspection

Nursing staff told us they were invited to observe the PPG meetings where they were welcomed for suggestions to improve patient experience. The practice worked with the integrated neighbourhood teams, mental health services, local services, the Herts and West Essex Integrated care board (HWEICB) to target their key demographics. Leaders were planning for increased demand following a new housing development built in the area. They also told us of their challenges following the closure of a local GP practice which saw an increase of up to 2,000 patients.

The practice worked closely with the HWEICB who also carried out quality visits to support the practice at their request. GPs also received support from the LMC, a local medical statutory body representing all NHS GPs and who supported the practice GPs during this inspection.

The practice had effective working relationships with its Primary Care Network (PCN), mainly using additional staff through the additional roles reimbursement scheme (ARRS) to improve patients' access to care. The practice could also demonstrate how working in partnership with the PPG provided an opportunity for patients to share feedback. Patients now received text messages when their paper prescriptions were ready to be collected from reception.

The provider told us there was a knock-on effect after being placed into special measures following the 2023 inspection. Post inspection work saw a lot of resources being used which went into driving improvement. Policies were custom made for the practice rather than off the shelf and Practice index was installed a year ago and the provider was now rolling out new functions. All policies were moved to Practice index including training records, patient safety alerts, significant events and complaints records. The provider told us this Practice index which has audit trails was being used by their practice only and not the wider Primary care network (PCN) practices.

Leaders were also aware of improvements required in all areas. They were aware of the improvements required with scanning and coding which had not yet been rectified. There was mixed feedback from staff as whilst some of the staff talked positively about their experiences of joining the practice, moving to new roles, and receiving ongoing support and development, some did not share the same experiences. Staff that were positive about their new roles had come in from previous non- patient facing roles and therefore found primary care interesting and what clinicians had to deal with on a daily basis. They appreciated there was a lot more involved to patient care than prescribing antibiotics for a chest infection.The Herts and West Essex integrated care board (HWEICB) told us the practice had access to their Contracts and Quality support team who would visit the practice to offer support when required.

During our inspection, we observed the staff and leaders being eager to learn and take our feedback on board. They were responsive to requests for information and acknowledged there was still ongoing improvement work taking place.There was a focus on continuous learning, improvement and innovation. For example, they revamped the staff room and moved over the IT systems and a computer was installed behind the screen, staff could remote in via screen and Teams. They also hired a new cleaning company which saw their infection control scores improve. We saw innovative and somenotable practice as to how the practice invested in the different initiatives to celebrate and include all their staff in an effort to improve their morale. They invested resources in different activities and events for staff and we saw that they went above and beyond usual practice to promote their staff. The provider invested in events such as quiz nights 4 times a year where work and non-work-related questions were asked. Winner's prizes included an annual leave day. We saw evidence of summer BBQ events and festive parties, 1-year anniversary, birthday and festive celebrations, London away days, karaoke nights and pizza lunches for passing exams and long service awards for nurses. As a bonus event for the end of 2024, the provider planned a manicure and message day at work on one of the days in the staff room. Whenever there was a positive review that named a member of the team, they received a card and small box of chocolates. For the 2 main festive seasons, partners would meet to decide what they would purchase as gift bags for staff.

However, the systems and processes in place to ensure learning and improvement was not robust and monitoring was required to ensure consistency in all these areas of learning. This was due to gaps and weaknesses in processes and arrangements intended to identify and deliver learning and continuous improvement in areas such as significant events, duty of candour, patient care, complaints and overall governance of the practice. We were also notassured the provider was always transparent with us regarding how their patient complaints were being managed and subsequent learning. For example, they told us a patient did not wish to raise a formal complaint with them but the patient showed us evidence that they had submitted a formal complaint that had been acknowledged by the practice and we found similar cases in other complaints we reviewed. Despite the investment in staff activities, further improvement was required to support staff in the practice where they felt there were not supported or listened to in their day to day work, without any fear of retribution.