Archived: Little Lever Health Centre-2

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• 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 did not assess all quality statements in this key question. We only assessed the parts of the quality statements that were included in the warning notices we issued to the provider on 19 December 2024.

The service did not have a good learning culture. Staffing levels had not increased. Not all the required information relating to staff was kept. Incidents were not always investigated thoroughly. There were some issues with the management of medicines.

At our last assessment this key question was rated as Inadequate. This assessment was carried out to check if the provider had complied with the warning notices issued to them as an outcome of the last assessment. The rating awarded at this assessment remains Inadequate.

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.

The assessment of November 2024 found that significant events were not always discussed with a view to making improvements, and significant events identified due to prescribing errors had not been fully considered to ensure the errors were not repeated. The significant event policy was not being followed.

At this assessment the provider told us there had been no significant events recorded since the November 2024 assessment. However, we saw meeting minutes that indicated there had been one. The practice manager told us the case should have been a significant event, but the GP who identified it may not have realised it was the type of thing they should discuss. They could not remember the name of the person involved so it could not be discussed. The provider had updated the significant events policy, but it was still not being followed as this incident had not been recorded.

During the November 2024 assessment we saw prescribing errors from October 2024 that had not been analysed and discussed to prevent recurrence. A meeting to discuss these events with a view to learning from them was not recorded until 17 February 2025, some 3 months later.

One of the significant events from October 2024, that was discussed on 17 February 2025, included an issue regarding consent. The documented learning point was, “Patients 16 plus – always seek consent from patient before entering in discussion with Parent or insist on a joint consultation with parent and young person.” This learning was not accurate. Once children reach the age of 16, they are presumed in law to be competent and to be able to consent to their own treatment, and information should not be shared with a parent without the consent of the young person.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The assessment of November 2024 found the provider did not ensure 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. Recruitment procedures were not always adequate.

At this assessment we found there had been some improvements. The practice had obtained an employment history for staff, kept photographic identification for staff, and they had checked the professional registration of the locum GPs and the practice nurse. However, they did not hold evidence of why the employment ended for any staff member who had been previously employed in a position whose duties involved work with children or vulnerable adults.

Staff previously told us they did not feel there were enough staff for the practice to run smoothly. No new staff had been recruited since the November 2024 assessment. Meeting minutes from 22 November 2024 stated the practice would advertise for a healthcare assistant, and meeting minutes from 20 January 2025 stated they would advertise for a receptionist and a healthcare assistant. These posts were not advertised until week commencing 24 February 2025. The practice had also advertised for a reception manager. One of the reception staff had been made reception manager on a temporary basis, but they had not been given a job description, and reporting procedures were unclear.

Staff had previously told us they did not feel supported. They had told us they raised issues with the lead GP, but they were not dealt with. During this assessment, although we asked for feedback from all staff very little was provided. We were told that staff had been told by the lead GP not to speak to us.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The assessment of November 2024 found people prescribed medicines with specific risks did not always receive appropriate monitoring. As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor without visiting the practice. The results from those searches demonstrated the provider did not have a full understanding of required checks.

At this assessment we found some improvements had been made but there were still issues. Our clinical searches identified 12 people with asthma had been prescribed 2 or more courses of rescue steroids in the previous 12 months. The National Institute for Health and Care Excellence (NICE) guidance states people should be followed up to check their response to treatment within 48 hours. One had not been followed up. There was a concern as this prescription had been issued without any consultation being recorded. Prescriptions should not be issued without a documented reason. The provider could not explain how this had happened. We also found people had not always been issued with a steroid card when this was appropriate.