Little Lever Health Centre-2

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 assessed all quality statements in this key question.

The service did not have a good learning culture. Incidents were not always investigated thoroughly. Feedback was that there were not enough staff to provide a safe service. Not all the required staff checks took place. We found issues with the management of medicines. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Managers made sure staff received appropriate training.

This is the first inspection for this service since its registration with CQC at the current location. This key question has been rated as inadequate. We identified breaches of regulation in relation to safe care and treatment and fit and proper persons employed.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People usually felt supported to raise concerns and felt staff usually treated them with compassion and understanding.

Staff told us that significant events were discussed in meetings if they were relevant to all staff. However, they told us that meetings were infrequent. We saw that the most recent 3 practice meetings had been held on 21 March 2024, 21 May 2024 and 15 August 2024. Staff said they were informed of significant events on a ‘need to know’ basis.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The practice had a significant events policy, giving the procedure to follow for the recording and the analysis of significant events. This stated that examples of significant events included new cancer diagnoses, and events which resulted in a complaint. The policy was not followed. New cancer diagnoses were not recorded as significant events and we saw complaints, such as clinics running late, had not been recorded as significant events. The policy also stated significant events should be discussed at the following practice meeting. We saw discussions about some significant events had not taken place.

There had been 3 prescribing errors by the same GP since 27 October 2024. One of these had not been included in the practice’s significant events log. ‘No harm’ was recorded for all of them, but the potential harm had not been considered. One of the forms did not state how the error had been identified and who identified it. There was another prescribing error by the same GP earlier in October 2024. The significant event form, and the discussion held, did not focus on how to prevent the clinician making similar errors. The person, who had capacity to consent and was over the age of 16, was excluded from relevant the discussion and decision making process, even though family members were included. There being 4 prescribing errors by the same GP in 5 weeks had not been considered, so safeguards had not been put in place.

When people moved between services, there was a plan in place for what happened next, who would do what and all the practical arrangements were in place.

Managers and staff could explain how people moved between services. Staff understood their responsibilities for monitoring the progress of referrals.

Partners had no specific feedback on this area.

The service worked 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.

Most people felt safe and supported to understand and manage any risks. However, we saw an example of a safeguarding referral being made following an error by a GP. The practice had discussed details of this with the patient’s family, but not the patient even though they had the capacity to consent and were over the age of 16.

There was an understanding from staff and leaders of safeguarding and how to take appropriate action, although policies were not followed.

We received some feedback from partners about safeguarding assurance tools not being submitted in a timely manner and in enough detail.

The practice had a policy for safeguarding adults that had been adopted from a Royal College of General Practitioners (RCGP) policy. This names the provider as the safeguarding lead, deputy lead, and administration lead. It also referred to partners. The practice is an individual GP and there are no partners. The practice had a policy for safeguarding children that had been adopted from a NHS Bolton Clinical Commissioning Group (CCG) policy. CCGs were replaced by Integrated Care Boards (ICBs) in July 2022. The policy was not being followed; the checks required under the ‘safer recruiting’ section were not all being carried out.

People knew what to do and who to contact when they realised that things might be at risk of going wrong or their health condition may be worsening.

There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. For example, managers told us that people were able to request home visits to meet their care needs.

There were systems in place to monitor people who may need a follow-up appointment. People were prioritised when they were very unwell.

Leaders and staff considered how environments could keep people safe from psychological harm as well as physical harm. However, staff commented that it could get very noisy in the reception area when activities took place in the library, as the layout was open plan. Quiet private spaces were offered if patients asked to speak confidentially with staff.

Facilities, equipment and technology were mostly well-maintained and consistently supported staff to deliver safe and effective care. Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly.

The practice had health and safety, fire and premises risk assessments and actions plan in place to keep the environment safe for people. The Business Continuity Plan stated there was an emergency supplies box kept in reception, which was to be taken with staff if they had to vacate the building for any length of time. We asked the 3 staff members in reception for this, but they had not heard of it. The practice manager told us they kept in locked in a cupboard as it contained prescriptions. We saw the box, but it did not contain everything the Business Continuity Plan stated it would.

Most people felt they had considerate support delivered by competent people. The most recent National GP Patient Survey results showed that 91% of patients had confidence and trust in the healthcare professional they saw or spoke to. However, we saw some complaints about a GP, and they had been dealt with by that GP.

Most staff told they did not feel supported. They told us they raised issues with the lead GP, but these were not dealt with. Staff did not think there were enough staff for the practice to run smoothly. They said they had to cover other staff when they were on holiday or sick. They were able to take the time back, however, they said this meant they were short staffed at other times. On-line training was usually completed outside working hours due to low staffing, and staff could take the time back. The healthcare assistant had recently left the practice. Phlebotomy was now carried out by a trained member of the reception team, and this caused further staffing issues. Clinical staff told us they received support.

The recruitment policy stated all new staff must have a Disclosure and Barring Service (DBS) check. It said checks would be processed in house. We examined the personnel files of all staff. One staff member provided a DBS check from a job they were in 2 years previously, and another DBS check was carried out 6 months prior to the staff member starting work. Evidence that photographic identification had been verified was not held for all staff. Following the assessment the practice manager told us they had now obtained this. Not all staff had provided a full employment history. The managers told us a staff member had been previously employed by a GP Federation prior to joining their practice so they did not carry out all the usual pre-employment checks. The policy stated all staff must have 2 satisfactory references. No references had been sought for the 2 most recently employed staff members.

A check of professional registration had been carried out for the practice nurse and locum GPs when they started work, but they had not been repeated. The General Medical Council registration checks had not been repeated for the 2 locum GPs since February 2023 and January 2021, and the Nursing and Midwifery Council check for the practice nurse had not been repeated since 2015. The practice manager repeated the check while we were on the premises.

The appraisal policy stated staff would have an annual appraisal. Appraisals had been carried out recently, but they had not been conducted annually. Competence and performance of clinical duties was not mentioned in the appraisals for the nurse or phlebotomist.

People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic.

Staff knew who the infection prevention and control lead for the practice was. They felt supported in understanding infection prevention and told us they received appropriate training, such as hand washing. Staff who handled clinical specimens knew how to do so safely.

The premises were clean, and equipment used was well maintained which helped to protect patients and visitors to the practice as much as possible from the spread of infection. The chairs in the waiting room were wipeable, sufficient personal protective equipment and hand washing facilities were available in clinical areas. Clinical staff were observed as bare below the elbow as per guidelines.

There were clear roles and responsibilities around infection prevention and control. There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The practice completed regular hand washing and infection control audits, the results of these were actioned on to improve compliance.

Staff involved people in reviews of their medicines. There had been significant events raised due to prescribing errors, and people were not always involved in relevant discussions about these.

Staff received appropriate training on medicines management, but not all staff knew where emergency medicines were located. Staff managed medicines-related stationery appropriately and securely.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The practice did not hold all the suggested emergency medicines and risk assessments for their importance had not been completed. However, staff explained there was a pharmacy on site and other pharmacies very close to the practice.

The provider had systems to manage and respond to safety alerts and medicine recalls, but these were not always effective. People prescribed medicines with specific risks did not always receive appropriate monitoring. The practice nurse was not correctly authorised to administer some medicines; the provider had authorised Patient Group Directions (PGDs) prior to the nurse being named.

The pharmacy had identified 2 recent prescribing errors, and another 2 prescribing errors had also been identified by the practice. The same GP was involved in all of these. Safeguards had not been put in place to reduce the chance of these errors reoccurring.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. The results from the searches demonstrated the provider did not have a full understanding of required checks. For example, the searches identified 15 people with asthma had been prescribed 2 or more courses of rescue steroids. The National Institute for Health and Care Excellence (NICE) guidance states people with asthma should be followed up to check their response to treatment of oral steroids within 48 hours. We checked 5 of the 15 records in detail. None of these had been followed up on. The provider told us they were not aware of this guidance.

Staff usually took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this.