A GP surgery has been told it must take action after an inspection found that untrained staff were making clinical decisions for patients - leading to two serious incidents.

Cross Plain Health Centre, which has practices in Durrington, Tidworth and Shrewton, was inspected by the Care and Quality Commission (CQC) after concerns were raised regarding the role of GP assistants working in the practices.

Inspectors found that the centre was using the term GP assistant to refer to a number of roles, and that the system for ensuring that unqualified staff were only allocated duties “within their areas of skills and experience” was inadequate.

Two incidents involving GP assistants were recorded by the practice between April 2017 and March 2018.

In the first, a “potentially life-threatening” delay was created when a GP’s request for a patient referral was not sent. Inspectors found that the referral had been passed from one member of staff to another, one of them a GP assistant, but that the centre was “unclear as to the roles of these staff in completing actions or where the error lay”.

In the second incident the diagnosis of a fracture was delayed, and a CQC report said: “One of the root causes for the delayed diagnosis was an inexperienced clinician (who the practice told us was a GP assistant.”

The CQC report said the practice had not demonstrated how a repeat incident could be prevented.

The report also found that unqualified staff worked in a duty rota to provide triage appointments to patients and “there were times when the duty triage rota was being dealt with just by GP assistants”.

“They [the staff] were self assessing the tasks they were assigning to themselves and then carrying out these tasks without authorisation from a qualified clinician,” inspectors added.

The CQC has now taken state enforcement action instructing the practice to ensure all staff have received appropriate training for their roles, and that GP assistants are properly supervised.