Archived: 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

At our last assessment, we rated this key question as inadequate. At this assessment, the rating remains the same.

The provider was in breach of legal regulation in relation to safe care and treatment, and fit and proper persons employed.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The significant event (SEA) policy had been updated since our previous assessment. It stated the likelihood of the incident recurring would be recorded, but this had not been recorded for any of the significant events we examined. SEAs were recorded on different templates with different levels of detail.

We saw 4 recent SEAs had been raised following prescribing errors by the same GP. There was no effective learning from these SEAs, and no evidence the issues were monitored. One of the SEA forms we were provided with, regarding a prescribing error, had not been entered onto the practice’s formal system for recording and managing SEAs. This meant there was no effective way of monitoring the number, seriousness and actions from SEAs. SEAs were discussed in meetings, but minutes were very brief and did not contain enough information to inform staff of what had been discussed. We saw some discussions around SEAs that had not been recorded on the practice’s SEA recording system. The provider told us all SEAs should be recorded on this system and there was no other record of SEAs kept.

Our assessment of November 2024 found there had been 4 prescribing errors by this same GP within a recent 5 week period. Not all of these had been formally recorded as SEAs. Safeguards had not been put in place to minimise the chance of these errors recurring. A further assessment in March 2025 found the provider had updated their SEA policy but it was not being followed; SEAs had been identified but not formally recorded. At this assessment we found improvements had still not been made by the provider, and they had not identified repeated prescribing errors as a theme which required action to prevent future errors being made.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Systems to process information relating to new patients were not effective. The provider had a backlog of approximately 198 patients’ paper records in a cupboard awaiting digitisation. They did not know how long they had been there, but a team member told us none had been digitised since they started to attend the practice in August 2025. Although they told us another provider was contracted to carry out this task, and they would be digitised when there were enough to be processed, they did not know how many were required or when this would be.

Test results were not always managed in a timely way. We checked outstanding test results on the afternoon of 10 April 2026. Test results, including those that were outside the normal range, had not been looked at since 7 April 2026, when all results had been actioned. The provider told us they usually carried out appropriate actions immediately, but they had not had the chance due to them working alone while the salaried GP was on annual leave. They had not arranged cover for the salaried GP while they were on leave. They said they would prioritise the urgent test results and they would clear them that afternoon or night. There were 69 results outstanding that had not been looked at, and 31 were noted as outside the normal range. Approximately 20 of these were from 8 April 2026. The provider explained that the pathology laboratory telephoned a practice if a result needed urgent action. Following the assessment the provider told us, “Myself and my GP colleague, on a daily basis, look and action on all the lab reports”. Our observations during the assessment found this statement to be incorrect.

The provider and the practice manager told us that reception staff had and followed a triage sheet to ensure patients were offered the most suitable care option. We asked to see this but none of the 3 members of the reception team knew where it was kept. Also, 1 could not recall if they had ever seen it. Not having an effective triage system meant that the provider could not be assured patients with the most urgent needs were seen in a timely manner by the most appropriate person.

On the day of our unannounced assessment there was no GP at the practice until approximately 8.35am. Their first face to face appointment was 9.30am. The provider told us there were times in the morning where no clinician was available. They told us that if a patient needed them before they arrived, the patient would be informed that a clinician would telephone them back. At our next site visit, the following working day, the provider told us they had decided to change their working hours and always be in by 8am.Following the inspection the provider told us that on the day of our inspection a GP assistant was on site from 8am and the practice nurse was on site from 8.30am. They told us they were available remotely to provide clinical support when required

The safeguarding policies for adults and children had been updated since our previous assessment. However, the safeguarding adults policy named the deputy lead as a GP who had not worked at the practice for several months. The safeguarding children policy named the admin lead as a staff member who had not been at the practice for several months. The provider told us the current salaried GP was the deputy for adults and children. The practice nurse and practice manager told us the practice nurse was the deputy for adults and children. We spoke to a staff member who was unsure who the leads were but stated they would know where to find the policies to find out. However, the policies were inaccurate. It is important that staff know who the leads are so concerns can be escalated urgently as appropriate.

The safeguarding adults and children policies had a section detailing how to safely recruit new staff. This included the checks that should be carried out prior to employing new staff. We saw that not all these checks took place. Our assessment of November 2024 had highlighted the same issue. Improvements had not been made since then.

On 13 April 2026 we were provided with the practice’s records of staff training. There was no evidence in their personnel file or in the practice’s training records that the salaried GP had completed training in safeguarding adults. There was no record of a member of the administrative team, who had worked at the practice for 7 months, completing training for safeguarding children. They had completed their safeguarding adults training during the weekend inbetween our 1st and 2nd site visits, so had been working for 7 months with no safeguarding training. There was no record of the practice manager completing safeguarding adults training. They had completed their safeguarding children training during the weekend inbetween our 1st and 2nd site visits.

The provider did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available, but staff were unaware how it was maintained. There was a defibrillator available that was shared between the 3 GP practices in the building. The practice did not carry out its own checks to ensure it was available and ready for use and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

The provider usually detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained.

Although an annual health and safety risk assessment had been carried out, this was a general assessment and did not include a risk assessment of each area of the practice.

Most staff had been trained in fire safety and health and safety, but this training had not been a priority. For example, 1 staff member completed fire safety training 7 months after they started work, and another staff member who had started work 3 months previously had not completed either training course. Only 1 staff member was a trained fire marshal. The practice manager told us they were arranging for 2 other staff to complete this training. However, the practice meeting minutes for 19 January 2026 stated, “Arrange fire marshal training”, with a deadline of the next meeting, in February 2026. The minutes from 19 March 2026 stated, “Fire marshal training required”, acknowledging that it had not yet taken place.Following the inspection the provider provided evidence that in May 2026 1 other staff member had completed fire marshal training.

There was a business continuity plan in place which was monitored and reviewed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We checked the personnel files for the 4 staff employed since our previous assessment. None of the 4 files contained all the required information. The practice had reviewed its recruitment policy, but this did not contain enough detail to inform the manager what information they required for newly recruited staff. The need for a full employment history was not noted in the policy. The practice’s safeguarding policies included a section on safer recruitment, including the need to obtain 2 references, 1 of which should be from the most recent employer. This was not followed.

The practice manager told us that all Disclosure and Barring Service (DBS) certificates were held in the staff personnel files. There was no DBS certificate in the file for 1 member of the administrative team. The practice manager, who had been employed since 01/01/2026, had a DBS certificate from February 2022.

An employment history was held for the practice manager (start date January 2026) and the salaried GP (start date February 2026). However, these were not accurate; they were not up to date and did not contain either staff member’s most recent employment. There was no employment history held by the provider for a member of the administrative team. Another organisation advertised for staff on behalf of the provider, and the employment history had not been given to the provider for their records. This was provided during our assessment.

Reasons for leaving previous employment involving work with children or vulnerable adults was not always provided. One staff member had previously worked in healthcare, including in a care home. There were no references from any previous employer.

Our assessment of November 2024 highlighted these issues, and the provider put an action plan in place stating how they would ensure personnel records were complete. At this assessment we found improvements had still not been made.

Training was not well-managed. Records held by the provider showed that the practice manager had only completed 1 training course. Some staff had not been trained in safeguarding. One staff member, who had been employed for 7 months, had completed 9 of their 19 training courses during the weekend prior to our 2nd site visit. On the day of our 1st unannounced site visit they had not completed training, identified by the provider to be mandatory, such as in safeguarding, information governance, and fire safety. The practice manager told us that there would be a new training plan in place from the month of our assessment. An action plan put in place by the provider following our November 2024 assessment stated they would ensure all staff, “especially new hires”, received training. receive one-to-one supervision, training, and performance reviews, especially new hires. The evidence seen on this assessment showed that the action plan had not been followed.

The practice had updated its infection prevention and control (IPC) policy since our previous assessment. The updated policy did not state who the lead for IPC was. It had been highlighted during a staff member’s appraisal in August 2025 that the policy needed to be updated, with named contacts included. At the time of this assessment this had not happened.

We were supplied with 3 infection control audits stated to have been completed in January to March 2026. The front pages had not been completed so there was no record of the date they were carried out, who had carried out the audits, who the lead for IPC was or when the next audit was due. The 3 audits we were supplied with were completed identically, and all scored 79%. The ‘progress made’ sections of the audits had not been completed. There was no plan in place to monitor the audits with a view to improving the score.

All audits identified that a ceiling tile needed attention and that it had been reported in September 2025. There were no updates regarding this identified risk. The audit confirmed an IPC lead had been identified, but this was not noted in the practice policy. The IPC policy stated IPC training would be completed by all staff annually, and the audit stated this had happened. This was incorrect.

Hand hygiene audits were seen but were unclear. The practice nurse completed separate audit templates for clinicians and non-clinicians. For the non-clinicians, there was just 1 template, and each month an additional date was added. The first date, in January 2026, was prior to the date 1 staff member named on the template had commenced their employment. For the clinicians, the practice nurse was recorded as auditing themselves. This did not give the provider assurance that the system was accurate.

There was therefore limited assurance that the provider understood their responsibilities relating to IPC or monitored IPC issues effectively.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We saw that several significant events (SEAs) had been raised due to prescribing errors by 1 GP. We saw 4 of these were between January and March 2026. Meeting minutes we reviewed indicated that there had been other prescribing errors by this GP that had not been raised as SEAs. Some of the errors involved controlled medicines, including opioids. There are risks of serious harm to patients when controlled medicines are mis-prescribed, and the prescribing is associated with overuse, misuse or addiction. Misuse of opioids can be life-threatening. Other than the GP being reminded to carefully review doses, dates, and a patient’s history before prescribing, no action had been taken to minimise the risk of this happening again. Although several errors had been identified, there was no proactive check to ensure other prescribing errors had not occurred. The prescribing errors we found had the potential to significantly impact on the health of the patients involved. Our assessment of November 2024 had found similar issues and at this assessment no improvement was seen.

We carried out a series of searches on the practice’s clinical systems as part of this assessment. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring.

On the whole, the search results were positive. However, we saw that 18 patients had been prescribed bisphosphonate, used for treating bone related conditions, for 5 years or more. We checked 5 of these patients in detail. All 5 required a review, including a bone density test, to check if it was appropriate and safe to continue being prescribed the medicine. Following the assessment, the provider told us they would review these patients.

Medicines were stored securely and at appropriate temperatures. Staff checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines and controlled medicines. Staff stored medical gases, such as oxygen, safely.