Background to this inspection
Updated
21 April 2020
Blakewater Healthcare, (Roe Lee Surgery, 367 Whalley New Road, Blackburn, BB1 9SR,) is located in a purpose built, two storey premises on the outskirts of Blackburn. The premises has parking spaces, including designated disabled spaces and ramped access to facilitate entry to the building for people experiencing difficulties with mobility.
The practice also has a branch surgery (known as The Montague Practice) situated in Barbara Castle Way Health Centre, Simmons Street, Blackburn, BB2 1AX. Patients are able to access services at either premises.
We visited both the main and branch sites as part of this inspection.
The practice delivers primary medical services to a patient population of approximately 10827 people via a general medical services (GMS) contract with NHS England. The practice is part of the NHS Blackburn with Darwen Clinical Commissioning Group (CCG). It is registered with CQC to provide the regulated activities diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures and maternity and midwifery services.
Male and female life expectancy (77.8 and 80.8 years respectively) for the practice population is similar to local averages and below national averages (79 and 83 years respectively). The practice’s patient population consists of a slightly lower proportion of older people, with 13.8% being over the age of 65 compared with the national average of 17.4%. Conversely the population of children under 18 years is higher at 24.8% compared with the national average of 20.6%. The locality caters for a lower proportion of patients with a long-standing health condition at 46.8%, compared to the national average of 51.4% and has lower levels of unemployed people; 1.2% compared with the national figure of 4.2%.
Information also published by Public Health England rates the level of deprivation within the practice population group as two on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The practice is staffed by three GP partners (two male and one female) and three long term locum GPs (one male, two female). The GPs are supported by two advanced nurse practitioners, two practice nurses and two health care assistants. Clinical staff are supported by a business manager, a practice manager and a team of administrative and reception staff.
The practice is open between 8am and 6.30pm each weekday apart from Friday, when extended hours appointments are offered from 6.45am in the morning. Patients are also able to access additional extended hours appointments, which are offered from local hub locations by the local GP federation on weekday evenings, and at weekends.
Outside normal surgery hours, patients are advised to contact the out of hours service by dialling NHS 111.
Updated
21 April 2020
We carried out an announced comprehensive inspection at Blakewater Healthcare on 11 March 2020 as part of our inspection programme to follow up concerns identified at our previous comprehensive inspection visit in August 2019.
At our inspection in November 2018 we rated the practice as requires improvement overall with key questions safe and well led rated as requires improvement. The follow up comprehensive inspection in August 2019 identified ongoing issues and concerns and the practice was rated inadequate overall with ratings of inadequate for providing safe and well led services. The practice was rated requires improvement for all population groups and for providing effective, caring and responsive services. The practice was placed into special measures and a warning notice issued for breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good governance).
A follow-up inspection on 13 January 2020 was undertaken to assess the progress achieved by the practice in implementing their plan to meet the legal requirements identified in the warning notice for the breach of regulation 17. That inspection identified good progress in improving the quality of service and meeting the requirements of the regulation.
The inspection reports for the November 2018, August 2019 and January 2020 inspections can be found by selecting the ‘all reports’ link for Blakewater Healthcare on our website at
We carried out our most recent inspection in order to ensure the practice had implemented appropriate improvements.
We have rated this practice as good overall.
We visited both Blakewater Healthcare, at Roe Lee Surgery, the main location and The Montague Practice, the branch location as part of this inspection.
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.
The inspection found significant improvements in the key questions safe and well led and both of these are now rated good. We rated the practice as good for providing caring and responsive services. The practice is rated as requires improvement for four of the six population groups and for providing effective services.
We rated the practice good for providing safe, caring, responsive and well led services because:
- A quality improvement plan had been implemented and effective progress and achievement made in improving service delivery in many areas.
- The practice systematically reviewed the service it provided and recognised and used opportunities provided by feedback, significant events and complaints to improve.
- The practice had implemented systems to ensure they provided care in a way that kept patients safe and protected them from avoidable harm.
- Staff dealt with patients with kindness and respect and involved them in decision about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
- There was recognition that published patient feedback was below local and national averages. The practice undertook their own patient feedback surveys and implemented plans to improve the patient experience.
We rated the practice as requires improvement for providing effective services as improvements are required for four population groups including People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students) and People whose circumstances make them vulnerable because:
- Performance data was below target levels, including immunisation achievements for one- year old children.
- The practice implemented a range of activities to improve cervical screening, however achievement data remained over 10% below the national target.
- Achievement against the quality outcome framework (QOF) had deteriorated on the previous year’s performance and was below local and national achievement.
- Evidence of care planning including for those at end of life and that preferred place of death was monitored was not available consistently.
The areas where the provider should make improvements are:
- Record care and treatment plans including palliative care plans that detail patients’ preferences and place of death consistently, and review these to identify learning and improvements for patients.
- Continue with the planned programme to improve achievements against the Quality Outcome Framework (QOF).
- Implement the planned action to improve achievements for cervical screening and immunisations of one-year old children.
- Improve systems to identify and support patients who are also carers.
I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.
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