The Care Quality Commission
  • Doctor
  • GP practice

The Weavers Practice

Overall: Good read more about inspection ratings

High Street, Rishton, Blackburn, Lancashire, BB1 4LA (01254) 884217

Provided and run by:
The Weavers Practice

Important: The provider of this service changed. See old profile

All Inspections

17 August 2023

During an inspection looking at part of the service

We carried out an announced follow up inspection at The Weavers Practice on 15 and 17 August 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring – Not inspected. (Rated Good July 2022)

Responsive - Good

Well-led - Good

This inspection was a follow up focused inspection. We had previously inspected the GP service on 14 July 2022. That inspection identified shortfalls in meeting the required standards and the GP practice was rated as requires improvement overall with key questions safe, effective and well led rated as requires improvement with caring and responsive key questions rated as good. We issued 2 requirement notices for breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment and regulation 17 Good governance.

The inspection reports for this service can be found by selecting the ‘all reports’ link for The Weavers Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection to follow up breaches of regulation from a previous inspection undertaken in July 2022. At this inspection we reviewed 4 key questions: safe, effective, responsive and well led. We found improvements in all the areas previously identified including:

  • Systems to ensure medication reviews were undertaken and recorded comprehensively.
  • Up to date staffing records including recruitment checks, professional registration, immunisation status, training records and appraisal.
  • Up to date training in safeguarding at the appropriate role specific level.
  • Regular audits for Infection prevention and control (IPC) supported with spot checks.
  • Monitoring of prescribing practice for those working in advanced clinical roles.
  • Progress to formalise and record the monitoring of advance clinical practitioners consultation and clinical decision making.
  • The establishment of a patient participation programme (PPG) with one meeting held.
  • Improved records for the uptake of childhood immunisations.

How we carried out the inspection.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting face to face staff interviews and using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Reviewing evidence from the provider, including the action plan following the inspection in July 2022.
  • Reviewing data available in the public domain.
  • A site visit.
  • Speaking with patients after the inspection visit.

Our findings

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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice team recognised the challenges of ensuring patient access to the right clinical care and treatment and was working with the primary care team on a quality improvement initiative to seek ways to improve patient access to timely appropriate care and treatment.
  • The way the practice leadership team worked with their staff promoted the delivery of high-quality, person-centre care.
  • The nursing staff team had the autonomy and support of the practice to develop strategies and protocols to support patients with end of life care and to understand and better self-care with health conditions such as diabetes .

Whilst we found no breaches of regulations, the provider should:

  • Implement the planned system to record the monitoring of patient consultations for those team members working in advanced clinical roles.
  • Update the complaints procedure to include a timescale of when complainants can expect a response to their concerns.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

14 July 2022

During a routine inspection

We carried out an announced inspection at The Weavers Practice on 14 July 2022.

Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective -requires improvement

Caring - good

Responsive - good

Well-led – requires improvement

This was the first inspection of this GP practice under this registered provider.

Why we carried out this inspection.

This inspection was a comprehensive rating inspection where we reviewed all five key questions.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This included:

  • Conducting some staff interviews using video conferencing as well as face to face
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A site visit
  • Speaking with patients

Our findings

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 requires improvement overall

We found that:

  • Some clinical monitoring checks had not been undertaken and some medication reviews were not recorded to a consistent safe standard. The practice acknowledged this and was taking immediate action to address these issues.
  • Systems of monitoring and record keeping for staff recruitment, clinical professional memberships and staff immunisation status required improvement. Staff training records did not identify consistently the level of safeguarding training staff had received.
  • Staff appraisals had not been undertaken and full staff meetings including clinical meetings were held infrequently.
  • Audits for Infection prevention and control (IPC) had not been undertaken although there was good evidence that Covid-19 adjustments had been implemented.
  • Systems to monitor clinical decision making and prescribing practice for those working in advanced clinical roles were informal.
  • A restoration action plan to improve many of the areas identified by this inspection was in the early stages of implementation.
  • Staff told us they were committed to working as a team and providing a good quality service to patients but would welcome improved systems of communication at the practice.

However:

  • The GP practice was split between two locations, a main location and a branch location. The practice management team were in the process of aligning systems and processes across both sites.
  • Patients we spoke with were wholly positive about the care and treatment they and their families received.
  • Patients told us they could get an appointment when they needed one and that the doctors were responsive to their healthcare needs.
  • The practice offered bespoke person centred care to vulnerable, frail, older and housebound patients. They employed a nurse practitioner whose role was community based, visiting these groups of patients.
  • Staff told us the GP practice was a good place to work and they were supported.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic and continued to do so now restrictions had changed.

We saw an area of outstanding practice:

  • The practice nursing team had developed a patient information leaflet called, “Medicine Sick Day rules”. The information leaflet provided easy read guidance for patients advising them what medicine they should stop taking whilst experiencing a short period of vomiting, diarrhoea and or high fevers (such as a norovirus). The list included medicines for high blood pressure, anti-inflammatory pain killers, diuretics, and medicines for diabetes. This provided patients with the guidance and assurance they needed without having to contact the GP surgery.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards.

The provider should:

  • Explore ways of involving patients in how the service is delivered and continue to canvas patients to restart a Patient Participation Group (PPG).
  • Monitor performance for childhood immunisations and continue to promote uptake of cervical screening.

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