May 20, 2024

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Church Langley Medical Practice in special measures following highly critical inspection

6 min read

THE Care Quality Commission (CQC) has dropped the overall rating for Church Langley Medical Centre from good to inadequate following an inspection in November. 

Church Langley Medical Centre has also been known as Dr M Kisenyi & Partners. 

The practice’s ratings for safe, responsive, and well-led have also dropped from good to inadequate. Its ratings for effective and caring have dropped from good to requires improvement. 

The service is now in special measures which means it will be kept under review by CQC and re-inspected to check on the progress of improvements.

Hazel Roberts, CQC deputy director of operations in the east of England, said: 

“When we inspected Church Langley Medical Centre, we were concerned to find its leaders had poor oversight of multiple issues affecting people’s safety and weren’t always acting promptly to improve the service. 

“For example, while most staff were hard-working and focused on people’s needs, leaders hadn’t always ensured staff had all the skills and knowledge they needed to keep people safe. 

“Additionally, some medications and equipment weren’t stored properly. We found an oxygen cylinder which staff hadn’t realised expired in October 2022, despite making daily checks of medical emergency equipment. This could have put people in danger during an emergency. 

“Data from the GP patient survey showed people’s experiences at the practice worsening over the past two years, but leaders hadn’t always used people’s feedback to make improvements. Likewise, the practice recorded incidents when things went wrong but couldn’t always show evidence they’d taken action to stop it from happening again in future. 

“We’ve told the service where improvements are needed and will be monitoring the practice closely to ensure these are carried out urgently.” 

Inspectors found: 

  • Many people were cared for in carpeted clinic rooms, which were hard to clean and risked spreading infection. This had also been identified in an infection prevention and control audit by the local integrated care board. The provider and the landlord had plans to replace the carpets and improve the building’s front entrance by early 2024. 
  • People weren’t always able to access appointments in a timely way. Leaders had made changes to the practice’s appointment system in response to feedback, though it will take time to assess the outcome of this. 
  • The practice’s safeguarding systems weren’t always comprehensive, which could put people’s safety at risk. 


  • People’s feedback described most staff as kind and respectful. 

A spokesperson for Church Langley Medical Practice said: “The practice acknowledges the findings of the inspection and are working closely with the CQC, ICB and other agencies to address the areas highlighted.”

A fuller statement was published on their website:

They stated:

The Care Quality Commission (CQC) has published its report into our practice and given us a rating of ‘inadequate’ following an inspection in November 2023. 

Whilst we do not fully agree with everything the CQC raises in their report, we note there are identified areas that the practice were aware of. The practice already had action plans in place to rectify, prior to publication of this report.

Since the inspection staff at the practice have worked hard to make improvements in many areas and continue to strive to provide the best clinical care possible. 

While we note the findings of this report, we are disappointed that the report does not reflect the action plan we put in place to address the areas of concern.

Some of the improvements we have already made include:

  • Refurbishment within the practice including to our reception area.
  • Staff and patient engagement exercises
  • Relaunch of our Patient Participation Group

We would welcome more members to join our Patient Participation Group – Please contact the practice if you would like to join.

The full CQC report can be found on the CQC website. 

We know many of you already share your feedback with us through our family and friends survey, we continue to strive to provide best clinical care possible with the resources we have, and this is reflected in our latest family and friends survey results. We want to thank all of you for your invaluable feedback and engaging with the practice to shape how we operate. The practice is looking forward to our re-inspection by CQC to demonstrate the improvements made. If you have feedback or questions relating to the CQC report, its findings, or recommendations please telephone the practice and request to speak with Cait.



We rated the provider inadequate for providing safe services because:

Systems and processes to keep people safe and safeguarded from abuse were not consistently implemented.

Staff vaccinations had not been maintained in line with UK Health and Security (UKHSA) guidance.

There were gaps in systems to assess, monitor and manage risks to patient safety.

Vaccines were not appropriately stored to ensure they remained safe and effective.

Appropriate standards of cleanliness and hygiene were not met.

The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the provider requires improvement for providing effective services because:

There were examples of potential missed diagnoses of some long term conditions.

Management of people with long term conditions was not always in line with national guidance.

The practice was unable to demonstrate that all staff had the skills, knowledge, and experience to carry out their roles.

We rated the provider requires improvement for providing caring services because:

National GP Patient Survey showed that patient satisfaction about their experience of the practice had decreased and was below local and national targets.

The practice had not undertaken an analysis of the needs of the local population.

We rated the provider inadequate for providing responsive services because:

National GP Patient Survey results were below local and national averages and patients were not able to access appointments and treatment in a timely way.

Complaints were not always used to improve the quality of care.

The practice did not adequately seek and act on feedback from patients.

We rated the provider 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.


The provider must:

  • Provide care and treatment in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standardsof care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed to meet theneeds of patients.

In addition the provider should

Complete risk assessments of emergency medicines arrangements.

Take action to manage the ongoing management of historical safety alerts within the national alerts system policy.

Improve the coding of patients within clinical systems.

Improve the process for managing test results, to ensure timely review of abnormal test results.

Take steps to review all patients on long-term steroids to ensure that all patients prescribed oral steroids for an asthmaexacerbation are following up in accordance with NICE guidelines.

Continue efforts to identify and undertake second cycle audits to promote quality improvement.

Implement systems to manage, control and mitigate risk relating to the practice.

Continue to take action to reinvigorate an active Patient Participation Group (PPG).


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