A SADDLEWORTH medical centre has been told to improve after inspectors found it fell short in key areas.
Lees Medical Practice has been rated as ‘requires improvement’ by the Care Quality Commission (CQC) after finding a number of issues.
They include gaps in CVs of employed staff, including unclear employment history, no references and no naming of practices they previously worked at.
Application forms were also signed after the start date, two at the interview date, one after the offer letter but before the start date and one on the start date.
CQC inspectors on August 25 and 29 found the practice had made improvements in the areas of safe care and treatment and good governance but other concerns were found.
They also found patient satisfaction had declined in certain areas.
And in a report, they said it needs to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care and ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Inspectors stated: “The provider had failed to establish systems and processes that operated effectively to ensure compliance with requirements to demonstrate good governance.
“In particular, policies such as the recruitment, complaints, and fire safety policies were not being followed. There were discrepancies between guidance, such as for infection prevention and control.
“The system for managing significant events and complaints was not effective. The system to ensure all staff received appropriate training was not effective.
“The provider had failed to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying out of the regulated activity. A health and safety risk assessment had been carried out but was not accurate.
“The provider had failed to have systems and processes in place to ensure staff were of good character or had the required qualifications, skills or experience required for their role.
“The provider had failed to ensure all clinicians were registered with the relevant professional body. In particular, professional registration checks were not routinely carried out during the recruitment process and on an ongoing basis.”
Issues over safeguarding and training were also found, including the statement: “We saw that one staff member had completed 29 training courses since we announced the inspection. 15 courses had been completed in one day.
“We saw no evidence of any safeguarding training for one long-term locum clinician and another long-term locum clinician had last completed safeguarding adults training over three years ago.
“The practice manager told us they did not hold disclosure and barring service (DBS) certificates for staff members but did note the reference number and the date of the check, along with evidence they had been carried out.
“There was no record of any DBS check for three of the four long-term locum clinicians. We saw a DBS certificate was held for the fourth, this was dated May 2018.
“The practice’s recruitment policy stated, ‘Clinical roles or those that otherwise involve contact with patients will usually require a DBS check before the successful candidate starts in the position.’
“We saw no evidence of a DBS check being carried out for the practice manager.”
Lees Medical Practice is part of a wider network of six GP practices, the Oldham East Primary Care Network (PCN).
Now it has been told it must send the CQC a report that says what action they are going to take to meet these requirements.
Saddleworth Independent has approach Lees Medical Practice, on Athens Way, for a response to the report.
