Church Langley Medical Practice in special measures following highly critical inspection

General / Thu 28th Mar 2024 at 07:41am

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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20 Comments for Church Langley Medical Practice in special measures following highly critical inspection:

Mrs Lisa J Coates
2024-03-28 08:16:18

That's not my experience at all, I find the practice great, always able to get an appointment when needed, the online call back service is great, receptionists are helpful and friendly, Doctors and nurses, compassionate and spend time on you...moved here 2 years ago, family of 4 and all of us have no complaints! Excellent service 👌🏼

2024-03-28 08:46:39

I offered, many times over the past 3 years or so to carry out an audit , free of charge , to ensure they were CQC compliant. I was ignored every time . You reap what you sow .

2024-03-28 08:59:47

The problem with Church Langley is that care varies radically and seems to consistently be good for some people and pretty consistently for others. It's very clear that is the experience of many frequently voiced through reports on local social media groups. Within my own family generally, over decades I've found CL to be good whereas other family members have found it more than disappointing (failing over ten years to get a critical diagnosis). Unfortunately most of the best doctors, (those most people want to see) there burn out or leave relatively quickly. Like many practices it seems overloaded with too many patients.

2024-03-28 09:25:42

#"and pretty consistently BAD for others."

C Wood
2024-03-28 10:18:58

I never get a face to face appointment at my surgery even when requested and have been sent to out of hours doctor at Nuffield House where nothing is ever followed up and does not appear on my notes. It is a constant battle - I will say the staff are always polite but not very helpful

2024-03-28 13:52:49

Not a surprise but then that could be said of other surgeries in Harlow. At my own surgery I recently had to argue with the receptionist for 30 minutes that the doctor couldn't change what the specialist had prescribed. More recently although wanting to book an appointment on the 25th March for my next B12 booster no appointment is available until the 8th April

2024-03-28 14:02:04

There have been many good doctors at the practice. However the good ones tend not to stay. That says much about the managing partners. I've noticed a gradual deterioration over the last few years. Getting a face to face appointment has not been easy at times and routine appointments take an eternity if an are available at all; hence everyone exaggerates their symptoms to get an emergency same day appointment.

Jo Frost
2024-03-28 14:47:07

I have lived in Church Langley for 20 years and always had great service for all my family from the practice. That has not always meant face to face with a doctor, sometimes it has been online, or phone consults with a nurse practitioner or paramedic practitioner. Whatever contact I have had has been professional, I have felt listened to and been given appropriate treatment or signposting. I am sure improvements will be made but I have to say that you can hear the unacceptable way the staff are spoken to by some patients, and the range of non-urgent conditions which really take up far too many requests for appointments, and could be dealt with by home treatment or advice from a pharmacy. The NHS is like any other service - if you want good service then be a considerate service user!

2024-03-28 16:37:44

They should get rid of Dr Kuti if he hasn't already gone! He is vile and does not know how to speak or treat people. He is sooo rude and does not care. Behaves as if he is better than everyone else. He is the problem at that place!

2024-03-28 17:27:49

The Hamilton Practice should be looked at too , ive been pushing for over a year for help , to no avail and have been threatened to be struck off , if i continue you asking for help, im not rude , always polite and even today been reminded about it , so now too scared to say too much to them incase i get struck off . Trying top use the NHS app is useless ive seen at times its closed even at 2pm when it opens, go moaned at for sending non emergency emails in as i could not get all info to fit on the app

Lee Raymond Knight
2024-03-28 18:03:27

The practice started going downhill when Dr Sandles was sacked 😢, I know he had his own personal issues but he was a very good Doctor. ✌️

2024-03-28 19:35:32

Doctor Sandles was a really nice doctor who listened & cared. Doctor Sanfilipo was great but not been there for many years. All the good people have left, Nurse Sharon was really caring and thanks to her being so thorough when the Doctor wasn’t she took time to read through my notes, it could have been a whole different story.

Peter Finkleston
2024-03-28 19:46:22

I and my late wife, became patients in 1999, when we moved to Harlow. Over the years there have been some very good doctors and staff, and a few not so good. A few months ago, I gave a Five Star review of the surgery on the NHS site, because of how well I’d been looked after. After the last year or so, the standards of all the staff, receptionists , nurse’s,prescription clerks, and certainly the doctors, have been excellent. If I felt I needed to see either the doctor or a nurse, if I phoned early, I got a call back, and saw the that day. The inspection may have shown some technical issues to be resolved, but patient care is not one of them. Full details supplied.

Paul Wilson
2024-03-29 08:39:44

The visit from CQC was long overdue the practice should not take on any more patients until they can cope with the ever increasing numbers.

Nogin the nog
2024-03-29 12:53:02

Nice peaple who work in there but like every thing else with NHS just over whelmed to maney people

2024-03-30 22:59:40

The CQC report was long overdue and I agree with their findings. It has declined for some time and patients like me have suffered from it. A wake up call for the partners and let’s hope improvements are made urgently.

2024-03-30 23:01:44

The CQC report was long overdue. The practice had declined for some time and patients like me have suffered from it. A wake up call for the partners and let’s hope improvements are made urgently.

2024-03-31 14:34:18

I have lived here 26 years and always had excellent service from everyone here including paramedics and nurses .I agree such a shame we lost Dr sandals and Dr San filippo and previously Dr Loxley all great doctors

Sandra hamill
2024-03-31 14:35:00

I have lived here 26 years and always had excellent service from everyone here including paramedics and nurses .I agree such a shame we lost Dr sandals and Dr San filippo and previously Dr Loxley all great doctors

2024-04-01 09:47:44

We moved here to CL 3 years ago, and was really pleased with our experiences with the practice. However over the past year the service has gone completely downhill. Myself and my daughter have had reason to complain, these complaints have been totally ignored. I’m never able to get an appointment, it’s really worrying, especially as someone in their 70,s I have had cancer in the past, and always had good care. So I’m now really concerned about being able to access that care again should I need to, and to care in general.

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