Blakewater Healthcare

We carried out an announced comprehensive inspection at Blakewater Healthcare on 20 August 2019 to follow up areas identified as requiring improvement at an inspection in November 2018. The August 2019 inspection identified limited improvement and the practice was rated as Inadequate overall with key questions Safe and Well led rated as inadequate and Effective, Caring, Responsive and all the population groups rated as requires improvement. We issued a warning notice for breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance).

The full comprehensive reports for November 2018 and August 2019 inspection can be found by selecting the ‘all reports’ link for Blakewater Healthcare on our website at

This inspection was an announced focused inspection carried out on 14 January 2020 to assess the progress achieved by the practice in implementing their plan to meet the legal requirements identified in a warning notice for breach of regulation 17. We did not rate the service or key question Well led at this inspection. The practice rating remains inadequate overall. A further comprehensive inspection will be carried out in the near future in accordance with our inspection methodology to further monitor improvements and update the practice ratings accordingly.

At this inspection we found:

• Good progress in meeting the requirements of the warning notice had been achieved.

• A comprehensive quality improvement plan was being implemented and effective progress was being made in improving service delivery in several areas.

• The GP provider had brought in a support team to help implement the changes required to develop, implement and improve systems and processes to ensure comprehensive oversight of both managerial and clinical risk.

• Governance arrangements and effective processes for managing risks and issues and performance were now in place and evidence indicated these arrangements were having a positive impact.

• Systems to ensure safe recruitment and infection control and prevention were effectively implemented were established.

• A clinical audit plan was being implemented.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Blakewater Healthcare (also known as Roe Lee Surgery) on 20 August 2019 as part of our inspection programme.

At the last inspection in November 2018 we rated the practice as requires improvement overall. Key questions safe and well led were rated as requires improvement. The issues identified as requiring improvement included: recruitment processes, systems to improve the management of incoming correspondence, and gaps in oversight and management of the governance of the practice.

At this inspection we followed up on breaches of the Health and Social Care Act (HSCA) Regulated Activities (RA) Regulations 2014 we identified at the previous inspection on 7 November 2018. These included Regulation 19 Fit and proper persons employed and Regulation 17 Good governance.

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected
• Information from our ongoing monitoring of data about services and
• Information from the provider, patients, the public and other organisations.

We have rated this practice as inadequate overall. Despite the provision of an action plan following the inspection in November 2018 we found limited improvements at this inspection. We visited both Roe Lee Surgery, the main location and Montague Surgery, the branch location as part of this inspection.

We rated the practice as inadequate for providing safe services because:

• Processes around auditing infection prevention and control were ineffective. The main treatment room at the Blakewater Healthcare premises had cuts in the examination couch, flaking paint on one wall and sticky residue from tape across cupboard doors and wall tiling.
• Evidence that learning from significant events was available in meeting minutes however the essential steps to mitigate risk of reoccurrence and maximise learning by amending protocols or policies was not in place.
• Workflow processes being piloted at the practice were subject to ad hoc quality monitoring, despite areas of improvement being identified.
• GPs confirmed they were up to date with sepsis training. However sepsis awareness training for the staff team had not been undertaken and there was limited information about sepsis available in the practice.

We rated the practice as inadequate for providing well-led services because:

• While the practice had a clear vision, that vision was not supported by a credible strategy or a system of quality improvement.
• Governance arrangements and effective processes for managing risks and issues and performance were inadequate.
• Some improvements in recruitment processes had been made since our inspection in November 2018 but gaps were noted in the recruitment records we viewed.
• Actions to improve the service identified at the inspection in November 2018 were not effective or had not been addressed.

We rated the practice as requires improvement for providing effective, caring and responsive services and all the population groups because:

• Some performance data was below target levels, including immunisation achievements for one year old children and cervical screening.
• We observed that staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Feedback through the patient survey was below that of the local and England averages.
• Opportunities provided by complaints to improve service delivery were not always recognised.

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Ensure specified information is available regarding each person employed.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Provide staff training and awareness in sepsis
• Enable complaints literature to be readily accessible for patients.
• Take action to improve achievements for cervical screening and immunisations of one year old children.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as requires improvement overall. (Previous rating November 2017 – Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

We carried out an announced comprehensive inspection at Roe Lee surgery on 7 November 2018 in response to concerns raised with us.

At this inspection we found:

• The practice had negotiated a challenging period of transition since merging with another local practice and incorporating a branch site a year ago. There had been a high turnover of staff at the branch site, although staff told us how the situation had improved over recent months.
• There were gaps in the practice’s governance arrangements resulting in risk management processes not being comprehensive, for example in respect to recruitment procedures and training oversight.
• While the practice had a range of documented policies and procedures in place, we found examples where these either had not been followed, or lacked sufficient detail to adequately describe the processes to which they related.
• The practice had some systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice documented investigations resulting from them and improved their processes. However, some staff found it difficult to demonstrate awareness of recent incidents and we found communication channels to disseminate learning was at times informal.
• The practice ensured that care and treatment was delivered according to evidence- based guidelines and reviewed the effectiveness and appropriateness of the care it provided.
• Staff involved and treated patients with compassion, kindness, dignity and respect. Patients felt positive about the quality of care and treatment they received. The practice’s results from the national GP patient survey were higher than local and national averages.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

• The provider should implement a formal process of monitoring clinical decisions made by staff working in advanced roles in order to be assured staff are working within their competencies.
• Actions completed on receipt of patient safety alerts should be logged in order to provide a clear audit trail of what has been done.
• Complaints literature should be easily accessible for patients
• Processes around auditing infection prevention and control measures should be improved. Audits should incorporate both practice sites.
• Communication channels should be formalised to ensure learning from significant events and complaints is maximised and shared efficiently with the wider practice team.

 Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice