Medical centre gave wrong vaccine to patient

The City Road Medical Centre was given the lowest rating of ‘inadequate’ by the Care Quality Commission (CQC) following a visit from inspectors earlier this year.

But the centre has now hit back at the CQC, slamming the health visit as unfair and claiming that the outcome was decided ‘before the visit’.

Bosses said they wanted to ‘assure patients we continue to provide the excellent care they know we provide’.

The practice, at 5 City Road, Edgbaston, was given the rating in a report published last week, with the individual areas of safety, effectiveness of service and effectiveness of leadership all given the lowest rating individually.

The centre did far better on how caring services were and whether or not they were well led, scoring ‘good’ in both of these areas.

However the result of the report means the centre will now be placed into special measures, with a follow-up inspection scheduled for the near-future.

During the inspection, which was carried out in February of this year, inspectors noted a number of issues, including concerning statistics regarding female genital mutilation (FGM).

They also noted the ‘significant event’ involving a wrongly administered vaccine.

The report said: “We were told due to an error with the wrong vaccine being given, the vaccinators had stopped doing this role until appropriate training had been completed, however on reviewing a sample of patients’ records we found the vaccinators were still carrying out this role.

“The patient was contacted to discuss the incident.”

The report continued: “There were 73 patients recorded as having undergone female genital mutilation (FGM) or a history of FGM.

“On reviewing the list of patients, we found 11 to be adult males and four were male children. There was no evidence to support why the female patients had been flagged as having a history of FGM on the clinical system.

“On reviewing staff records we found that the practice did not have completed disclosure and barring checks (DBS) for new employees. Previous DBS checks had been accepted and we saw no evidence that risk assessments had been completed in their absence

“We found non-clinical staff were stopping medications and completing medicine reviews with no specific training or clinical oversight.

“The practice was unable to demonstrate effective leadership. Systems in place were putting patients at risk and the lead GP and management team did not have the capability to lead effectively and drive improvement.

Significant

“We identified significant failings in the care of patients, this included: safeguarding concerns not being addressed, overall management of patients with long term conditions and a lack of clinical oversight to ensure patients were receiving adequate care and treatment.”

The medical centre received a rating of ‘good’ at its last inspection, which took place before the pandemic.

Now the manager of the centre, Sherell Abrol, believes that the circumstances of the pandemic were not given enough consideration when the CQC returned for another visit this year.

“We are disappointed with the outcome of this visit but can assure patients we continue to provide the excellent care they know we provide,” she said.

“We found several things with this visit unfair but our arguments regarding the evidence presented were not accepted and the outcome is what has been presented.

“In 2019 in normal service provision times our practice was rated good. We continued to provide excellent care with our QOF outcome being high and service satisfaction being good.

“In January during lockdown, in the middle of Covid vaccination roll out we were contacted telling us a visit was required.

“The CQC published operating procedure during Covid was not followed in our case so we were not given the same allowance as in the case of other practices at the time. The evidence we were presented with was largely opinion in many areas drawn from coding errors on less than five patients. This was used to generalise in several areas.

“The overall impression was on receipt of the report that the outcome was decided before the visit and then written to fit the outcome.

“We were criticized for PAT testing equipment being eight weeks late knowing we were in lockdown and companies were not sending staff to do visits in premises. The evidence that our cervical cytology screening was not adequate was uptake in June 2020 when all labs had ceased nationwide collecting samples from practices for cancer screening for cervical cancer. This was then extrapolated that enough was not being done by the practice in several areas.

“We ‘did not reflect to improve our service’ based on the fact that we had no complaints. We could only reflect and improve if we reviewed our complaints and address the issues raised in their assessment.

“Audits were not being done was another example: How many practices during the pandemic were able to carry out patient audits? When we presented that audits were indeed done they were rejected that the patient population used was too small: practice population 2,500. How can we counter that being a small inner city practice?

“These reports are meant to be supportive. Does this read like a supportive report? Very little if any allowance was made that we were in the middle of lockdown in unusual circumstance in primary care in inner-city Birmingham.

“We will work towards our revisit and hope we will have a fair and reasonable visit and a good if not excellent outcome.”