GP surgery branded ‘not safe’ and placed in special measures
Little Lever Health Centre 2 on Mytham Road was rated inadequate overall following an inspection by the Care Quality Commission (CQC).
This is CQC’s first inspection of the practice which is run by Dr Thiruppathy Subramanian, and provides services to around 3000 people in the Lever area.
As well as being rated as inadequate overall, it was also rated as inadequate for being safe, effective and well-led.
It was rated as requires improvement for being caring and responsive.
Inspectors found:
- Multiple prescribing errors that weren’t properly investigated or learned from.
- Required staff recruitment checks weren’t consistently carried out putting people at risk of being cared for by people that weren’t suitable to carry out their roles.
- Inadequate staffing levels affected people’s experience and treatment.
- The service didn’t adequately monitor people with long-term conditions putting them at risk of coming to harm.
- Leaders didn’t learn from significant events to share with other staff and prevent it from happening again.
- Young people’s rights to confidentiality weren’t always respected.
- There was limited wider engagement with people using the service, for example the patient participation group only met annually.
However:
- There was good support for vulnerable people using the service.
- Leaders had a strong understanding of local community demographics.
CQC had served Dr Subramanian with warning notices in December for three regulation breaches in order to focus their attention on making rapid improvements in those areas of; safe care and treatment, making sure fit and proper people are employed, and good management.
There had been four prescribing errors in five weeks – all by the same GP.
Inspectors said that there was no attempt to put in place safeguards or stop the clinician from making similar errors.
They said that the service did not always “have a proactive and positive culture of safety based on openness and honesty”.
They said: “Lessons were not always learnt to continually identify and embed good practice.”
Inspectors said the clinic had a “significant events policy” to record and analyse significant events, but that it was “not followed”.
They said that new cancer diagnoses were “not recorded as significant events” and that complaints were not recorded either.
The CQC said that the clinic was not safe (Image: PA) Have a story? Get in touch at eoin.mccaul@newsquest.co.uk
Inspectors reported: “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.”
Inspectors said that the complaints policy was not clear and the complaints log did not detail if the complaint was upheld or not.
They said: “The provider responded to complaints made about them, with no input or oversight from anyone else.
“Responses were not always appropriate.”
The policy said that new complaints would be discussed at practice meetings, but inspectors said that the meeting minutes showed this wasn’t the case.
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Staff told inspectors that they didn’t feel supported, and that issues raised with the lead GP weren’t dealt with.
They said they didn’t think there was enough staff for the clinic to run smoothly.
Inspectors said: “Phlebotomy [taking blood samples] was now carried out by a trained member of the reception team, and this caused further staffing issues.”
CQC has placed the practice into special measures. As a result, they will be able to access additional support from NHS England and the Royal College of General Practitioners to drive improvements in the provision of care.
Alison Chilton, CQC Deputy Director of Operations in Greater Manchester, said: “When we inspected Little Lever Health Centre 2, we found a service where serious concerns about people’s safety and how the service was being managed weren’t being adequately addressed.
“People weren’t receiving the standard of care they have a right to expect, and we placed them into special measures as a result in order to protect people.
“We found significant issues with medicines management and some concerning examples of prescribing errors that hadn’t been properly investigated or learned from. The practice wasn’t managing people’s care effectively, and their required health monitoring wasn’t always consistently carried out.
“Additionally, we were worried about staffing levels and found the practice had limited management presence, with no leadership oversight for more than half of its operating hours. This contributed to delays in appointment times, with people regularly waiting over an hour to be seen.
“The practice’s approach to complaints and significant events was also concerning. Complaints weren’t being properly investigated or responded to, and there was insufficient learning from incidents. In some cases, complaints about the GP were being reviewed by the same GP with no independent party reviewing evidence or drafting responses.
“We have placed the practice in special measures, which means it will be able to access additional support from NHS England and the Royal College of General Practitioners. CQC will continue to closely monitor the service to ensure people are safe whilst improvements are being made and will return to check on their progress.”
Source – INDIA TV
