Background to this inspection
Updated
15 May 2020
Little Lever Health Centre, Dr Jain and Dr Subramanian, is on Mytham Road, Little Lever, Bolton, Lancashire, BL3 1HQ. It is a single storey purpose-built health centre practice in the centre of Little Lever and is a shared location with two other GP practices. The practice has been based at Little Lever Health Centre for over 40 years and offers services to people across Farnworth, Breightmet, Great Lever, Little Lever and Bury.
The practice is registered with the CQC to carry out the regulated activities diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
The practice provides NHS services through a General Medical Services (GMS) contract to 2814 patients. This is a decrease of approximately 300 patients since the last inspection in 2017. 7% of patients are 75 years or over and the demographic is mainly white British with recent increasing numbers of patients from Eastern Europe and the Middle East. The practice is a member of Bolton Clinical Commissioning Group (CCG).
Little Lever Health Centre provides primary medical services in Bolton from Monday to Friday. The surgery is open Monday to Friday 8am to 6:30pm and extended hours Tuesday until 8:30pm. Appointments with a GP are available:
Monday 9:00 - 12:00 16:00 - 18:30
Tuesday 9:00 - 12:00 16:00 - 20:00
Wednesday 9:00 - 12:00 17:00 - 18:30
Thursday 9:00 - 12:00 16:00 - 18:30
Friday 9:00 - 12:00 16:00 - 18:30
Additionally patients can access GP services in the evenings from 6.30pm to 9.30pm and on Saturdays and Sundays from 9am to 1pm through the extended hours service.
Services are provided usually by two full time partner GPs. However, the lead partner and registered manager is currently on long term sick leave. A part time locum temporarily undertakes sessions on an as and when basis. There is no practice nurse and patients who wish to see a nurse (for example for cervical screening) are redirected to the out of hours provision. There is a health care assistant for phlebotomy and some areas of long-term condition management.
The patient age profile for the practice is similar to the CCG average. Life expectancy for males is 77 years, which is in line with the CCG average of 77 years and below the national average of 79. Life expectancy for females is 82 years, which is above the CCG average of 81 and below the national average of 83. Information published by Public Health England, rates the level of deprivation at number five on the deprivation scale. Level one represents the highest levels of deprivation and level ten the lowest.
Updated
15 May 2020
We undertook an annual regulatory review of Dr Jain and Dr Subramanian (Little Lever Health Centre) on 15 November 2019. The review indicated that several changes had occurred at the practice since the previous inspection in 2017 which could have an impact on one or more of the key questions. An inspection was therefore agreed.
We inspected Little Lever Health Centre on 20 March 2020 as part of our inspection programme. The practice was given an overall rating of Requires Improvement with the following key question ratings:
Safe – Requires Improvement
Effective – Requires Improvement
Responsive – Requires Improvement
Well-led – Requires Improvement
The key question Caring was not inspected but the rating of good was carried over from the previous inspection.
This was a focused inspection and the key questions planned for review were Effective, Responsive and Well Led. During the inspection we found concerns with medicines management and the inspection team therefore opened the key question of Safe at that point.
We rated the practice Requires Improvement for providing safe services because:
- Safeguarding, fire and infection control training was not up to date for all members of staff.
- Actions required following a fire risk assessment had not been monitored or completed.
- There was no evidence of actions required following an infection control audit being completed and the cold chain was not well-managed.
- The process for managing significant events, safety alerts and prescribing was not effective and learning from specific actions could not be demonstrated.
Immediately following the inspection, we received assurance and evidence that the risks associated with patient safety had been reviewed and new systems were implemented to oversee and reduce any future risk.
We rated the practice Requires Improvement for providing effective services because:
- Although the aim of the practice was to provide the best possible health care for their patients, we found that systems did not support best practice, for example guidance was not proactively monitored to ensure it was being followed.
- There was no evidence of any two-cycle audits and where it had been identified that a second audit was required these had not been completed.
- Training was not well-managed; there were gaps in staff training and it was difficult to ascertain what training had been carried out as some evidence was kept in individual personnel files and not recorded elsewhere.
- There was no formal clinical supervision of employed clinical staff and appraisals did not support learning and development.
Immediately following the inspection we received assurance and evidence from the practice that the risk to effective services had been reviewed and new systems had been implemented to oversee and reduce any future risks. For example a system to improve clinical audit and ensure appropriate staff learning, support and development.
The practice was rated Good for providing caring services at a previous inspection.
We rated the practice as Requires Improvement for providing responsive services because:
- The practice nurse had left the practice in June 2019 and another practice nurse had not yet been secured. There was no female clinician at the practice.
- Patients wishing to see a nurse were referred to the extended hours service which meant they could not be seen at their own GP practice between the hours of 8am and 6.30pm.
- The registered manager who worked full time at the practice (the lead partner) was on long-term sick leave. A part time locum was filling in.
- Not all staff were being utilised to the best of their ability and the remaining GP was seeing all patients for everything, including vaccinations, immunisations and the management of long-term conditions.
- There was no contingency plan or pro-active monitoring to establish if the needs of the practice population were being met.
- Complaints were not appropriately monitored and responded to.
Immediately following the inspection, we received assurance and evidence that the risks associated with responsive care had been reviewed and new systems were being implemented to oversee and reduce any future risk. For example, the practice had begun a process to monitor verbal complains and were in the course of advertising for a practice nurse and a salaried GP.
We rated the practice as Requires Improvement for providing well-led services because:
- There were two new practice managers in post since March 2019. They were still in the process of implementing and updating protocol, policies and procedures. We identified areas of concern in recruitment, training, complaints, health and safety, fire and medicines management.
- Although their aim was to include all members of the team in decision-making, not all staff described an open culture where discussion and learning took place, and some staff described an “us and them” feeling.
- The practice was not able to corroborate with evidence the information they had provided at the annual regulatory review. For example, we did not see monthly searches to identify patients at risk or regular monthly meetings where concerns were discussed, lessons were learned, and changes were applied.
- We found that there was not always a whole team approach with regard to providing care and staff worked in isolation.
Immediately following the inspection, we received assurance and evidence that the risks associated with good governance had been reviewed and new systems were being implemented to oversee and reduce any future risk. For example, there was a standardised meeting agenda to discuss significant incidents, patient safety alerts, good prescribing, and other issues associated with good practice working. All members of staff would be involved in those meetings to ensure that communication was effective.
We have rated the practice as requires improvement overall in keeping with the evidence found on the day. The concerns that we found related to all population groups and we have therefore rated the population groups as requires improvement overall.
The practice must:
- Ensure care and treatment is provided in a safe way to patients
- Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care
- Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment
- Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care