The Care Quality Commission
  • Doctor
  • GP practice

Bakersfield Medical Centre

Overall: Good read more about inspection ratings

141 Oakdale Road, Nottingham, Nottinghamshire, NG3 7EJ (0115) 940 1007

Provided and run by:
Bakersfield Medical Centre

All Inspections

25 January 2023

During a routine inspection

We carried out an announced comprehensive inspection at Bakersfield Medical Centre on 25 January 2023. Overall, the practice as good.

At our previous inspection in June 2022 the practice was rated as requires improvement overall. The safe key question was rated as inadequate, effective, response and well-led were rated as requires improvement and caring was rated as good.

We also carried out an announced follow-up inspection on 11 October 2022 to review compliance with the warning notices served following our previous inspection on 7 June 2022 but the inspection was not rated. Actions had been taken to address most of the areas of the breaches identified in the warning notices and it was evident improvements had been made. However, some required actions were not yet fully completed or embedded. The ratings from June 2022 therefore still applied and were reviewed at this inspection.

The full reports for previous inspections can be found by selecting ‘all reports’ link for Bakersfield Medical Centre on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this comprehensive inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

Following this inspection the practice is now rated as good overall and for all key questions.

How we carried out the inspection/review

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

This included:-

  • Conducting staff interviews 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).
  • A staff questionnaire which was submitted electronically.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider to be submitted electronically.
  • A short site 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:

  • Improvements had been implemented and evidenced in relation to repeat prescribing, management of health and safety, infection prevention and control and records in relation to staff vaccinations.
  • The practice had implemented systems that supported the appropriate and safe use of medicines.
  • Practices had processes in place to keep people safe and safeguarded from abuse.
  • 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.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to review access in terms of patient experience and satisfaction in collaboration with others such as their patient participation group and external agencies.
  • Take steps to review historic patient safety alerts to ensure patients are identified and appropriate actions are taken.
  • Continue to encourage patients to attend for cervical screening and childhood immunisations.
  • Take steps to improve the number of NHS Health checks completed.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

11 October 2022

During an inspection looking at part of the service

We carried out an announced follow-up inspection at Bakersfield Medical Centre on 11 October 2022 to review compliance with the warning notices served following our previous inspection on 7 June 2022.

In June 2022 the practice was rated as requires improvement. The safe key question was rated as inadequate, effective, response and well-led were rated as requires improvement and caring was rated as good.

This follow-up inspection on 11 October 2022 was to review compliance with the two warning notices which had to be met by 22 August 2022 but the inspection was not rated. The ratings from June 2022 therefore still apply and will be reviewed at a further inspection to take place within six months of the publication of June inspection report.

The full reports for previous inspections can be found by selecting ‘all reports’ link for Bakersfield Medical Centre on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a review of information, which included a remote review of clinical records and a site visit.

To check compliance with the warning notices we served for breaches in Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance.

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 spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Undertaking remote access to the practice’s patient records system to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider to be submitted electronically.
  • A site 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 have not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

However, we found that:

Actions had been taken to address most of the areas of the breaches identified in the warning notices and it was evident improvements had been made. However, some required actions were not yet fully completed or embedded.

We found that:

  • Appropriate standards of cleanliness and hygiene were met. However, some improvements were still required.
  • Further improvements were required in relation to the monitoring and assessment of patients’ health in correspondence received from secondary care.
  • Clear and effective process for governance and managing risks, issues and performance need further work.
  • The practice were able to show that staff had the skills, knowledge and experience to carry out their roles.
  • The system to manage complaints information had improved since the last inspection.

We found a continued breach of regulations. The provider must:

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

The provider should:

  • Continue to monitor the competence and performance of clinical staff who work in the practice.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

07 June 2022

During a routine inspection

We carried out an announced inspection at Bakersfield Medical Centre on Tuesday 7 June. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led – Requires Improvement

Following our previous inspection on 05 February 2020 the practice was rated Good for all key questions and population groups except families, children and young people which was rated as requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bakersfield Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This comprehensive inspection, including a remote review of clinical records and a site visit was conducted following concerns that were raised to the CQC.

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 spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • 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 short site 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 have rated this practice as Requires Improvement overall

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients could access care and treatment in a timely way.
  • The practice was unable to demonstrate effective leadership. The lack of adequate processes were putting patients at risk.
  • The management team we spoke with demonstrated a lack of knowledge to ensure effective processes were embedded to drive efficiency, manage risk and ensure safety in the practice.
  • Infection prevention and control was not monitored effectively.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • The system to manage complaints was not effective.
  • We found that the system in place to manage significant events was not effective.

We found two breaches of regulations. The provider must:

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

In addition, the provider should:

  • Continue to encourage patients to attend immunisation appointments.
  • Continue taking action to improve the uptake of national screening programmes such as 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

05/02/2020

During a routine inspection

We carried out an announced comprehensive inspection at Bakersfield Medical Centre on 5 February 2020 as part of our inspection programme.

We previously inspected the practice on 20 December 2018 and rated it as requires improvement overall, with safe and well led services being rated as requires improvement. We rated the practice as good for providing effective, caring and responsive services. At that inspection, we rated all population groups as good.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have appropriate systems in place for the safe management of medicines.
  • The practice needed to improve learning from significant events.

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

  • The practice’s governance arrangements required improvement to ensure that all significant issues were identified and addressed and the practice learned and made changes from investigations and audits where appropriate.

At this inspection in February 2020, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service is 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 have rated them good for older people, people with long term conditions, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health population groups. However, we have rated them requires improvement in effective for families, children and young people population group.

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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Improve the uptake of childhood immunisations and cervical screening to achieve national targets.

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

20 December 2018

During a routine inspection

We carried out an announced comprehensive inspection at Bakersfield Medical Centre on 20 December 2018 as part of our inspection programme. This inspection took place in response to concerns reported to the Care Quality Commission.

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 and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have appropriate systems in place for the safe management of medicines.
  • The practice needed to improve learning from significant events.

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

  • The practice’s governance arrangements required improvement to ensure that all significant issues were identified and addressed and the practice learned and made changes from investigations and audits where appropriate.

The overall rating for this practice was requires improvement due to concerns in providing safe and well-led services. However, the population groups were rated as good because patients could access timely and effective care and treatment.

We rated the practice as good for providing effective, caring and responsive services because:

  • Staff had the skills, knowledge and experience to carry out their roles. Performance data was generally in line with local and national averages. Consent was obtained in line with national guidance.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The area where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.

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

The areas where the provider should make improvements are:

  • Ensure that all staff have received fire safety and infection control training.
  • Ensure a record is held of staff immunisation status for all diseases recommended by Public Health England.
  • Review all consulting rooms to ensure patient privacy and dignity is maintained at all times during examinations, investigations and treatments.
  • Improve governance procedures to ensure that risks, issues and performance concerns are identified and managed effectively.
  • Improve quality improvement methods such as completion of full-cycle clinical audits to monitor and improve patient outcomes.

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

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

21 August 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out two announced comprehensive inspections at Bakersfield Medical Centre on 1 March 2016 and 1 December 2016. The overall rating for the practice following the December 2016 inspection was good but it was rated as requires improvement for providing well led services. The full comprehensive reports for the March 2016 and December 2016 inspections can be found by selecting the ‘all reports’ link for Bakersfield Medical Centre on our website at www.cqc.org.uk.

We carried out this announced focused inspection on 21 August 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 December 2016. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had improved the governance arrangements for using patient feedback from the national GP patient survey data to drive improvement in services.
  • The national GP patient survey results showed the majority of patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Arrangements for identifying, recording and managing risks and implementing mitigating actions had been improved. Specifically, the recording of searches and follow-up action taken in response to patient safety alerts and the review of patients on repeat prescription for medicines that are used to treat high blood pressure (ACE-inhibitors).
  • Practice supplied data for 2016/17 (yet to be verified and published) showed the practice had increased the uptake rate of the measles, mumps and rubella (MMR) vaccine in children aged five.

The areas where the provider should make improvement:

  • Continue to consider ways of increasing the patient participation group membership and regular engagement so as to improve and develop services within the practice.

  • Continue to review, monitor and act upon patient experience data to drive service improvement. This includes patient feedback relating to GP and practice nurse consultations (being involved in decisions about their care and being treated with care and concern).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bakersfield Medical Centre on 1 March 2016 and an unannounced inspection on 3 March 2016 to follow-up on concerns identified on the first inspection day. The overall rating for the practice was requires improvement with a rating of inadequate for the safe domain. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Bakersfield Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 1 December 2016 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 1 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • There were systems in place to monitor and maintain patient safety in the practice.

  • Staff understood their responsibilities to raise concerns and to report incidents and near misses. Incidents were regarded as opportunities for learning across the practice team and for improving patient care.

  • Clinicians assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Suitable arrangements were in place to ensure staff received appropriate training, professional development, supervision and appraisal.

  • Positive feedback was received from most patients about their care and treatment. Patients told us they felt treated as individuals and were involved in the planning and delivery of their care. Some patients felt improvements could be made to ensure all staff were caring and respectful and this was reflected in the National GP Patient Survey results.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs.

  • Feedback received from patients and comment cards was positive about the continuity of care offered, appointments running on time and the appointment system being easy to use which enabled them to access the right care at the right time. This was reflected within the National GP Patient Survey results on access to services and the practice’s responses in relation to this area were above the local and national averages.

  • The practice was located in purpose-built premises and was well equipped to treat patients and meet their needs.

  • The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result.

  • The practice had a clear vision which had quality and safety as its priority. The strategy to deliver this vision was regularly reviewed and discussed with staff.

  • Staff worked well together as a team and had addressed most areas highlighted in the March 2016 inspection.

However there were areas of practice where the provider must make improvements:

Systems and processes must be established and operated effectively to enable the provider to:

  • Ensure feedback from patients is used to drive improvements in the service by: using patient feedback relating to the quality of care offered by GPs proactively; reviewing the way the service is delivered and acting on areas of lower patient satisfaction. This includes the national GP patient survey results.

  • Ensure that potential risks are identified and mitigated by: improving the recording of searches and follow-up action taken in response to patient safety alerts and strengthening the processes in place for following up patients on repeat prescription for medicines that are used to treat high blood pressure (ACE-inhibitors) to ensure they receive timely reviews.

There was an area of practice where the provider should make improvements:

  • Consider ways to increase the uptake rate of the measles, mumps and rubella (MMR) vaccine in children aged five.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

1 and 3 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bakersfield Medical Centre on 1 March 2016 and an announced inspection on 3 March 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and to report significant events. However, the recording of investigations undertaken and dissemination of learning required strengthening.

  • Patients were at risk of harm because effective systems and processes were not always in place to keep them safe. We found some risks to patients and staff had been assessed but immediate and / or appropriate action to mitigate these risks had not always been carried out. This included risks related to fire safety, health and safety, and the environment.

  • Staff referred to evidence based guidance and used it to assess patients’ needs and improve patient outcomes. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Clinical audits demonstrated improvement to patient outcomes and quality of care.

  • Staff worked well with multi-disciplinary teams and other health care professionals to ensure effective care planning and delivering of integrated care for patients.

  • Feedback from patients about their care and interactions with practice staff was strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • However, data from the national GP patient survey showed patients rated the practice lower than others for most aspects of care relating to consultations with GPs.

  • The practice offered a high degree of flexibility for patients to access the practice and obtain GP appointments when needed. Our review of the appointment system, feedback from patients and care home staff, and the national GP survey results showed the practice provided excellent access to GP appointments.

  • As a result of good GP access and effective care planning, the practice had one of the lowest rates of secondary care usage compared to other practices within the CCG. This included low rates for emergency and outpatient referrals, first patient outpatient attendances and accident and emergency (A&E) attendances.

  • The practice managed complaints well and took them seriously. Information about how to complain was available and easy to understand.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

  • The practice had a vision in place but not all staff were aware of this. The governance arrangements in place required improvement to ensure the delivery of good quality care and effective management of risks.

The areas where the provider must make improvement are:

  • Ensure the systems in place to identity, assess and manage all risks including fire safety, health and safety, the environment and premises are robust.

  • Ensure the actions that are planned to address risks related to infection prevention and control are completed.

  • Ensure all notifiable incidents are reported timely to the Care Quality Commission.

The areas where the provider should make improvement are:

  • Ensure contemporaneous records are kept of staff and the management of regulated activities. This includes meeting minutes, more detailed recruitment files and significant events.

  • Ensure all staff are supported to understand the practice vision and values.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice