Brain clinic blunder left one patient in a hospital in Birmingham and now it has been warned

The clinic now has six months to deliver significant improvements, or they could have their registration cancelled.

Hunters Moor Neurorehabilitation Centre

A brain clinic in Birmingham is in danger of being closed after a medicine mishap left one patient hospitalised.

Hunters Moor Neurorehabilitation Centre in Hall Green had previously been rated good. Still, Care and Quality Commission officers visited the clinic after concerns were raised about safety and management. An inspection report published last week found severe problems at the clinic, with one patient being taken to hospital after crucial medicines were not given - despite the record saying they had.

The inspection officer said: “The provider did not ensure service users' medication was safely managed. Medicines were not always administered as prescribed. We saw that prescribed medication had been recorded as issued when it had not been consumed, resulting in a person being admitted to the hospital.

“Risks to people had not been sufficiently assessed. The 'risk assessment summary' for one service user rated them as having a considerable risk of setting fires. However, risk assessments had not been completed about these known risks, and there were no recorded plans for managing these.”

The officer also raised concerns about the “inconsistent” management. Whilst admitting that services across the country are short-staffed due to the pandemic, the report still took issue with communication and the culture at the clinic.

“Reported incidents involving service users had not been consistently acted upon. The analysis of incidents had not been communicated to staff. Communication with staff was poor, and the needs of staff were not always looked for and acted upon.”

Staff at the clinic described communication as “poor” and said morale was low. One staff member said: "We complete incident forms but didn't know what happens to them; we never see any analysis. We don't get supervision or meetings. We haven't had them, there is no support, and we don't feel we are listened to."

Patients were also quick to complain to officers about the lack of care. One said: "I was frustrated by the lack of feedback, not knowing what is happening." Another said: "I do not know the full name of the person in charge; I do not know who to contact."

The clinic now has six months to deliver significant improvements, or they could have their registration cancelled.