Story Highlight
– Little Lever Health Centre rated ‘inadequate’ by CQC.
– Serious prescription errors noted, no monitoring occurred.
– Unsafe opioid prescriptions, 69 test results outstanding.
– FCNA Homecare rated ‘inadequate’, placed in special measures.
– Staff recruitment issues and missing training records reported.
Full Story
Concerns regarding patient safety and quality of care emerged this week as two health services in Greater Manchester received ‘inadequate’ ratings from the Care Quality Commission (CQC). A recent inspection revealed serious issues at Little Lever Health Centre-2 and FCNA Homecare in Hale, highlighting persistent challenges in managing healthcare delivery standards.
Little Lever Health Centre-2, located on Market Street in Little Lever, was flagged for multiple significant prescription errors attributed to a specific General Practitioner (GP). The CQC’s findings indicate a troubling lack of improvement or monitoring since previous inspections, where similar errors were noted as early as 2024. Patients were subjected to unsafe opioid prescribing practices, with the situation exacerbated by a lack of routine reviews to ensure that ongoing medication remained appropriate for their conditions.
The report disclosed alarming administrative oversights, particularly concerning test results. During the inspection, it was noted that there were 69 outstanding results, with 31 classified as requiring action due to being outside of normal parameters. Additionally, a concerning number of staff had not completed the necessary safeguarding training, raising questions regarding the centre’s commitment to patient safety. Confusion surrounded the designated safeguarding lead within the practice as paperwork referenced an individual no longer employed, with current staff unable to provide a clear answer when questioned.
The recruitment process at Little Lever also raised red flags, with several personnel files lacking the requisite Disclosure and Barring Service (DBS) checks and references. Employment history details for some staff members were found to be inaccurate, heightening concerns over the clinic’s hiring practices. Appointments at the practice were another area of criticism; a review found that only one in three appointments commenced on schedule. For 87 appointments assessed, nearly half were delayed by 30 minutes or more, and over a fifth saw patients waiting for 45 minutes or longer.
Despite the serious issues documented, patient feedback revealed a contrasting perspective; a national survey indicated that 93% of respondents expressed confidence and trust in their doctor, with 85% rating their GP as ‘very good’ or ‘fairly good’ in terms of care and concern. This highlighted a disconnect between patient perceptions and the operational realities of the practice, as it still maintained a ‘good’ rating in the caring category.
In Bury, the inspection report was more positive for Radcliffe House, a home providing care for young people. The facility received a ‘good’ rating, with inspectors praising its understanding of resident needs and encouraging engagement in daily activities to foster independence among its young inhabitants. The home provided proactive safety measures, integrating lessons learned to continuously improve care standards.
Greenbank Medical Practice in Oldham also secured a ‘good’ rating, attributed to having qualified staff who received appropriate support and development. Patient comments reflected high satisfaction with the service, noting that “nothing is too much trouble.” However, an inconsistency in patient experiences was highlighted, with only 51% reporting a positive overall experience compared to a national average of 70%. In response, Greenbank implemented a triage system to better address patient needs, prioritising urgent cases and enhancing the telephone system to minimise wait times.
Conversely, FCNA Homecare, located on Ashley Road in Hale, received an inadequate rating due to non-compliance with several legal standards, particularly regarding consent, safety, and governance. The CQC report underscored alarming inadequacies in medicine management, indicating failures in timely responses to patients’ changing health conditions and the safeguarding of their rights. Documentation practices were weak, leading to staff lacking reliable, updated information to provide competent care.
Issues surrounding recruitment at FCNA were markedly severe, with notable gaps in procedures for onboarding staff. Missing induction records, references, and employment histories further compounded the risks associated with patient care. The absence of evidence showcasing the training in medication competencies and mental capacity assessment left the organisation unable to demonstrate that staff had adequate preparation to deliver compliant care.
Both locations’ ratings serve as a critical reminder of the necessity for rigorous adherence to safety protocols and governance in healthcare settings. The CQC’s role in inspecting and reporting on such services underscores its commitment to ensuring that patients receive the standard of care they deserve, but the findings illustrate continuing challenges in achieving compliance and assurance of safety across the healthcare spectrum in Greater Manchester. The cases at Little Lever Health Centre and FCNA Homecare spotlight the urgent need for improvement, not only in process and training but also in fostering an environment where patient safety and trust are paramount.
Our Thoughts
The series of prescription errors at Little Lever Health Centre highlights significant deficiencies in adherence to UK health and safety regulations, particularly the Care Act 2014 and the Mental Capacity Act 2005. To avoid such incidents, better governance and oversight processes should have been established, including regular monitoring and auditing of prescription practices as mandated by the Care Quality Commission.
Key safety lessons include the importance of staff training and competence in handling medications, compliance with safeguarding protocols, and ensuring timely management of patient test results. The lack of safeguarding training and incomplete recruitment files demonstrate a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, particularly Regulations 12 (safe care and treatment) and 19 (fit and proper persons employed).
To prevent similar occurrences, proactive measures such as improved staff recruitment protocols, ensuring completion of necessary training, and establishing a robust system for managing patient care and prescriptions must be implemented. Regular reviews and an effective governance structure are essential to foster a culture of safety and continuous improvement within healthcare settings.
















