Little Lever Health Centre-2

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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.

There was no formal succession plan. The business continuity plan was not accurate. No new staff had been recruited since our previous assessment. Learning was not a priority. Staff feedback was very minimal, and we were informed staff had been told not to speak to us by the lead GP.

At our last assessment this key question was rated as inadequate. As this assessment was to check the compliance of warning notices the rating remains unchanged.

This service scored 29 (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 there was no formal succession plan in place. There was a business continuity plan, but this was not accurate and did not effectively detail how the practice would manage if the lead GP was not available, Staff told us they were not listened to. There was no manager presence at the practice for over 50% of the time it was open.

At this assessment we found there was still no formal succession plan in place. The business continuity plan had been updated. It stated that if the lead GP was incapacitated the remaining locum GPs would provide cover. However, the locum GPs had a verbal contract only with the provider so did not have a responsibility to provide the cover. The business continuity plan also included some inaccurate information around the emergency box containing prescriptions.

We received feedback that the lead GP had told staff not to speak to us as part of this assessment, so we were unable to determine if some changes had taken place.

The lead GP had promoted a member of the reception team to reception manager on a temporary basis. This meant there was a manager available for more hours. However, there was no job description in place for the reception manager.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The assessment of November 2024 found that not all staff knew who the Freedom to Speak Up Guardian was, the policy was unclear, and staff told us their concerns about the practice were not taken seriously by the lead GP.

At the assessment we found the provider had updated their policy for Freedom to Speak Up and Whistleblowing. The correct external personnel were included.

We asked staff for their feedback, including feedback about the Freedom to Speak Up Guardian. We received very little feedback, and we were informed that the lead GP had told staff not to speak to us.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The assessment of November 2024 found governance processes were not effective. Practice meetings were infrequent, and locum GPs did not attend. Staff found it difficult to fulfil their roles as staff had not been replaced when they left and there was no cover when staff were off work. Some polices were inaccurate or not followed.

At this assessment we saw that no new staff had been recruited since November 2024. Although there was a temporary reception manager, this role had been given to an existing member of the team, with other team members not having the opportunity to apply for the temporary post. We were unable to determine how staff felt as we received very little feedback. The provider told us they were going to change how they held meetings, but at the time of the assessment no changes had been made. There had been a practice meeting on 22 November 2024, and the next one was held on 24 February 2025 so formal updates and discussions had not taken place with the practice team.

We saw that some policies, such as the significant event policy, had been update, but others, such as the complaints policy, had not.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.