Dr Sansome and Partners Also known as Weavers Medical

Updated 6 June 2022

The Provider, Dr McManus and Partners, has one location registered with the Care Quality Commission (CQC) which is a purpose-built facility; Weavers Medical, Prospect House, 121 Lower Street, Kettering, NN16 8DN. The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the Northamptonshire Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 20,600. This is part of a contract held with NHS England.

Patient demographics reflect the national average and information published by Public Health England rates the level of deprivation within the practice population group as five, on a scale of one to 10. Level one represents the highest levels of deprivation and level 10 the lowest. The practice population is predominantly white British (92%) along with small ethnic populations of Asian (4.4%) and mixed race (1.5%).

At Weavers Medical, the service is provided by four GP partners, 12 associate GPs, one locum GP, five nurse prescribers, two practice nurses, five healthcare assistants and a phlebotomist. The team is supported by a practice manager, assistant manager, executive assistant and reception supervisor, along with a team of administration and reception staff. The local NHS trust provides health visiting and community nursing services to patients at this practice.

Weavers Medical is a GP training practice. GP Registrars are fully qualified doctors training to work as a GP in general practice. At the time of inspection three GP registrars were in post.

The practice is open between:

• 8am and 6.30pm, Monday to Thursday
• 8am to 1.30pm and 2pm to 6.30pm on Fridays

As part of the Kettering locality GP extended access hub, patients can access extended hours appointments at Weavers Medical (same day and pre-booked appointments are provided by GPs, Nurse Prescribers, Clinical Pharmacists, Practice Nurses and other clinicians) outside of the core general practice hours. Appointments are available:

• 4pm to 8pm Monday to Friday
• 8am to 12.30pm Saturday
• 8.30am to 12.30 Bank Holidays.

When the practice is closed patients are directed to contact the out-of-hours GP services by calling the NHS 111 service.

Updated 6 June 2022

We carried out an announced inspection at Dr McManus and Partners on 12 May 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 26 February 2020, the practice was rated Good overall and Good for providing Safe, Caring, Responsive and Well-led services. The practice was rated as Requires Improvement for providing Effective services.

From the inspection on 26 February 2020, the practice was told they must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr McManus and Partners on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused follow-up inspection to follow up on the Requires Improvement rating for effective at the last inspection in February 2020. The practice was found to be in breach of Regulation 17 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. A requirement notice was issued to the provider under Regulation 17: Good Governance due to the area of non-compliance we found.

In February 2020, we rated the practice as Requires Improvement for providing effective services because:

• The practice had not met the minimum 90% target for three of four childhood immunisation uptake indicators.
• The percentage of women eligible for cervical screening was below the national average of 80%.
• Exception reporting for patients with long-term conditions, mental health and dementia were above the local and national averages.
• Meeting minutes, particularly in relation to significant events and complaints needed more detail on actions and learning.

In addition, we told the provider they should:

• Improve patient satisfaction for appointments and the ability to access the practice by telephone.

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 inspection was carried out in a way which enabled us to avoid an on-site visit. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Reviewing evidence sent in advance of the inspection to demonstrate action taken and improvements made.
• Speaking with staff via teleconferencing facilities.
• Undertaking remote clinical searches of the patient record system.

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 Good overall.

We found that:

• The practice had invested considerable, targeted efforts to improve uptake of both childhood immunisations and cervical cancer screening. This included provisions and adjustments to the service to ensure appointments continued to be available through the pandemic. Despite these efforts practice achievement was still below national targets.
• Evidence to demonstrate recall systems were in place and effectively managed to ensure patients received timely reviews of their health and medication.
• Specific focused clinical searches of the practice’s patient record system did not identify any patients at potential risk and we found effective management of patient’s conditions.
• Complaints handling was systematic and a detailed analysis of complaints was undertaken annually to identify any themes and trends. Investigations were thorough; both of complaints received and when trends were identified to ensure improvement in the quality of care and service delivery. For example, following receipt of multiple complaints regarding communication the practice took steps to improve patient experience. This included in-house discussions, customer service training and training on non-violent communication.
• Significant events handling was comprehensive. Learning from events was used to drive improvement in service provision. The practice used a system to risk rate significant events. In addition, significant events were classified as either clinical, governance or other to support analysis. Annual analysis of significant events was exhaustive and was discussed at meetings with staff to ensure learning was shared.
• Significant events were reviewed as standing agenda items at regular meetings with evidence of learning and dissemination where needed.
• The most recent results of the national GP patient survey (01/01/2021 to 31/03/2021) showed the percentage of respondents who responded positively to how easy it was to get through to someone at their GP practice on the phone was in line with local and national averages at 55%.
• The practice had installed a new telephone system which supported increased lines. A process had been introduced which enabled additional staff to support telephone answering when call waiting numbers exceeded a specified acceptable level. This process had proven successful in reducing call wait times and patient access to the practice by the telephone.

The provider should:

• Continue with efforts to encourage patient uptake of the childhood immunisations and cervical cancer screening programmes.

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