Eaves Lane GP surgery placed into 'special measures' - again

Date published: 02 June 2021


A Chadderton GP surgery has once again been placed into ‘special measures’ following a damning assessment after a review by Care Quality Commission inspectors.

Dr Anita Sharma’s Eaves Lane Surgery in Chadderton has seen its overall rating given as ‘inadequate’ again.

It was rated as ‘inadequate’ in three of the five main questions raised, namely are services safe?, are services effective and are services well-led?

It received a ‘good’ rating when asked are services caring?, and ‘requires improvement’ regarding are services responsive to people’s needs?

Dr Rosie Benneyworth BM BS BMedSci MRCGP, the CQC’s Chief Inspector of Primary Medical Services and Integrated Care, stated in a report: “Previously, an inspection was carried out on June 14, 2019.

“The practice was rated inadequate and placed into special measures.

“Two warning notices and a requirement notice were issued.

“We re-inspected the practice on February 7, 2020 and found the required improvements had been made.

“The practice was rated good overall and in all key questions, and it was removed from special measures.

“On January 20, 2021, we carried out an unrated focused inspection.

“This was following a Transitional Monitoring Approach (TMA) assessment where possible risks to patient safety had been identified.

“We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

“We issued warning notices in respect of Regulation 12 (safe care and treatment) and 17 (good governance) and a requirement notice in respect of Regulation 19 (fit and proper persons employed).”

A follow-up inspection took place on April 22, 2021, and the required improvements had not been made.

Dr Benneyworth added in the report: “In addition, we identified further areas of concern.

“We rated the provider as inadequate for providing safe services.

“Clinical staff were not correctly authorised to administer certain medicines.

“Some patients prescribed high risk medicines were not being appropriately monitored.

“Checks on the competence, training and experience of clinical staff were not routinely undertaken prior to them working at the practice.

“Not all pre-recruitment checks were carried out.

“Some significant event forms had been misplaced and full investigations had not been carried out.

“We rated the provider inadequate for providing effective services.

“The on-going clinical needs of patients were not managed consistently due to required monitoring not always taking place.

“Patients with poor mental health had consultations with a pharmacist who had not provided evidence of being sufficiently trained.

“Patients with potentially missed diagnoses were found. No formal checks were carried out on the competence of clinicians.

“We rated the provider good for providing caring services.

“Staff dealt with patients with kindness and respect and involved them in decisions about their care.

“We rated the provider requires improvement for providing responsive services.

“Complaints were not handled in a satisfactory manner.

“We rated the provider inadequate for providing well-led services.

“The practice had not made the improvements required following the inspection of January 20, 2021.

“Significant event and complaints information was missing so the practice could not confirm appropriate action had been taken.

“There was no Freedom to Speak Up Guardian and some staff had not heard of one.

“Some policies were inaccurate, lacked sufficient detail, or were not being followed.

“There was no system to identify staffing risks.

“The required training of clinical staff was not monitored.

“There was no system of quality assurance within the practice, and the governance systems in place were not effective in that safety risks had not been identified. “

Dr Benneyworth’s report concluded: “Due to the breaches of regulation identified we will be carrying out further enforcement action against the provider.

“I am again placing this service in special measures.

“The Care Quality Commission will refer to and follow its enforcement processes in taking action reflecting these circumstances.

“The service will be kept under review and if needed could be escalated to urgent enforcement action.

“Where necessary, another inspection will be conducted.”


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