The Care Quality Commission
  • Doctor
  • GP practice

Archived: Bayswater Medical Centre

Overall: Inadequate read more about inspection ratings

46 Craven Road, London, W2 3QA

Provided and run by:
Bayswater Medical Centre

All Inspections

09/07/2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of Bayswater Medical Centre on 4 June 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. A follow-up announced comprehensive inspection was undertaken on 3 February 2016 following the period of special measures. Although the practice had made improvements, and were removed from special measures, there were still concerns and the practice was rated as requires improvement overall.

We carried out an announced inspection on 27 July 2017 and, although, the practice had addressed the issues of our previous inspection we found new concerns and the practice remained rated as requires improvement. We carried out an announced comprehensive inspection on 10 May 2018 when we found that the practice had not addressed all the findings of our previous inspection and additional concerns were identified. The practice was rated inadequate overall and placed in special measures for a second time for a period of six months. In line with our enforcement procedures we issued two warning notices in relation to regulation 12: safe care and treatment and regulation 17: good governance of the Health and Social Care Act 2008. The full comprehensive report of the June 2015, February 2016, July 2017 and May 2018 inspections can be found by selecting the ‘all reports’ link for Bayswater Medical Centre on our website at www.cqc.org.uk.

We carried out an announced focused inspection of Bayswater Medical Centre on 9 July 2018. This was to follow-up on the two warning notices the Care Quality Commission served following the announced comprehensive inspection on 10 May 2018. The warning notices, issued on 25 May 2018, were served in relation to regulation 12: Safe care and treatment and 17: Good governance of the Health and Social Care Act 2008. The timescale given to meet the requirements of the warning notice was 6 July 2018.

Prior to this inspection on 9 July 2018, we were told by commissioners they had acted to address the immediate concerns in relation to patient safety and had suspended the practice from administering immunisations and provided clinical and managerial support to the practice. Specifically, this included full-time practice management support to facilitate a significant event and root cause analysis (a systematic approach to the investigation of serious incidents) process and liaise with the appropriate agencies in relation to the cold chain breach and a part-time nurse practitioner to ensure clinical effectiveness of cold chain policies and procedures and staff training. This support was ongoing at the time of our inspection. The practice had also been instructed by commissioners to close the practice list to new patient registrations.

At the inspection we found that the practice, in collaboration with external clinical and non-clinical support, had addressed most of the issues identified at our previous inspection. Specifically, we found the provider had:

  • Reviewed its systems and process to manage the cold chain and initiated a formal investigation into the cold chain breach.
  • Addressed the actions of the fire and Legionella risk assessments.
  • Addressed the actions of the Infection Prevention and Control (IPC) audit and arrangements in relation to IPC to mitigate the risk of infection.
  • Calibrated all medical equipment in line with guidance.
  • Implemented clinical protocols for healthcare assistants.
  • Initiated a formal system to act upon patient safety alerts.
  • Commenced some clinical audits.
  • Addressed gaps in staff training in line with guidance in relation to safeguarding, fire awareness, infection prevention and control, information governance and sepsis awareness.
  • Commenced regular structured clinical and practice meetings which demonstrate shared learning.
  • Entered in to a proposed practice merger.

However, we found:

  • Up-to-date competence training for ear irrigation for the healthcare assistant was not available.
  • Water temperature recordings did not meet the requirements for healthcare premises and there was no documented action taken where the temperatures had fallen outside the recommended ranges.
  • There was no evidence of a programme of continuous quality improvement.

Our inspection on 9 July 2018 focussed on the concerns giving rise to the warning notices issued on 25 May 2018. We found the practice had acted to address most of breaches of regulation set out in the warning notices. However, the current rating will remain and the practice will remain in special measures until the provider receives a further comprehensive inspection to assess the improvements achieved against all breaches of regulation identified at the previous inspection.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

10 May 2018

During a routine inspection

We carried out an announced comprehensive inspection at Bayswater Medical Centre on 4 June 2015. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. A second announced comprehensive inspection was undertaken on 3 February 2016 following the period of special measures. Although the practice had made improvements there were still concerns and the practice was rated as requires improvement. We carried out a third announced inspection on 27 July 2017. Although the practice had addressed the issues of our previous inspection we found new concerns and the practice remained rated as requires improvement. The full comprehensive report of the June 2015, February 2016 and July 2017 inspections can be found by selecting the ‘all reports’ link for Bayswater Medical Centre on our website at www.cqc.org.uk.

This inspection, on 10 May 2018, was an announced comprehensive inspection to confirm that the practice was now meeting the requirements that we had identified in our previous inspection on 27 July 2017. Upon publication of our previous report we asked the provider, under Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, to send us a written report of the action they would take to achieve the requirements of the Health and Social Care Act 2008, associated regulations and any other legislation we had identified they were in breach of. This was required by 20 October 2017. The provider failed to return the action plan despite reminders being sent. The provider only provided an action plan when it was requested following the announcement of this inspection.

This report covers our findings in relation to the requirements of our previous inspection and any improvements made since our last inspection.

The practice is now rated as Inadequate overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

At this inspection we found:

  • The provider had failed to submit CQC statutory notification requirements within the required timescale.
  • We found that the practice had not addressed all of the findings of our previous inspection and additional concerns were found.
  • Risks to patients were not assessed and well managed including legionella, equipment, fire safety, and infection control.
  • Clinical staff we spoke with were able to demonstrate how they assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Leaders did not consistently have the knowledge or capacity to prioritise safety and quality improvement. There was a poor track record in terms of maintaining improvement and the practice was reactive rather than proactive.
  • We found there was a lack of systems and processes established and operated effectively to ensure compliance with requirements to demonstrate good governance.
  • There was no evidence of regular structured or formalised clinical or practice meetings. The practice were unable to evidence how learning from significant events, patient safety alerts, clinical guidance and complaints was shared with staff.

The areas where the provider must make improvements are:

  • 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 of care.

The areas where the provider should make improvements are:

  • Amend the safeguarding children policy so it is practice-specific.
  • Review best practice in relation to the recognition, diagnosis and early management of sepsis and consider if the practice can appropriately assess all patients, including children, with suspected sepsis.
  • Continue to review and monitor patient outcomes in relation to childhood immunisations and the cervical screening programme.

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.

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

27 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bayswater Medical Centre on 3 February 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the 3 February 2016 inspection can be found by selecting the ‘all reports’ link for Bayswater Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 27 July 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 3 February 2016. This report covers our findings in relation to those requirements and any improvements made since our last inspection.

Overall the practice is remains rated as requires improvement.

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

  • Although risks to patients were assessed, the systems to address these risks were not implemented well enough to ensure patients were kept safe. For example, we found concerns in relation to infection prevention and control, medicines management, recruitment processes, staff training and appraisals.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Staff were aware of current evidence based guidance and were trained to provide them with the skills and knowledge to deliver effective care and treatment. However, clinical protocols were not available to support the scope of responsibility undertaken by the healthcare assistants.
  • Patients we spoke with told us they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

  • 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 of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvement are:

  • Consider the infection control lead undertaking enhanced training to support them in this extended role.
  • Address all actions identified in the fire, health and safety and Legionella risk assessments.
  • Continue to monitor patient outcomes in relation to the childhood immunisation programme.
  • Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.


Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

3 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bayswater Medical Centre on 3 February 2016. Overall the practice is rated as requires improvement.

The provider had been previously inspected on 4 June 2015 and was rated as inadequate for being safe, effective, caring, responsive and well led. As a result of this inspection, the provider was placed into special measures. On 8 June 2015 we served the practice a notice under Section 31 of the Health and Social Care Act 2008 to impose conditions in relation to their registration as a service provider. Bayswater Medical Centre were instructed to not to carry out any regulated activities at the branch site, 7 Golborne Road, and not to register any new patients at the main practice except for family members of existing patients for a period of six months.

This inspection was planned to check the action taken in response to findings of the inspection undertaken on 4 June 2015 to consider whether sufficient improvements had been made.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were assessed and well managed, with the exception of those relating to medicines management.
  • Data showed patient outcomes were mixed compared to the locality and nationally.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 provider was aware of and complied with the requirements of the Duty of Candour.
  • The practice had proactively sought feedback from patients and had recently developed a patient participation group.

The areas where the provider must make improvements are:

  • Implement a robust system for medicines management including stock control of medicines to ensure these are in date and fit for use.

In addition the provider should:

  • Complete the register for carers and consider ways to actively identify carers and provide appropriate support for them.

  • Develop a strategy to support the vision to deliver high quality care and promote good outcomes for patients.

I confirm that this practice has improved sufficiently to be rated ‘Requires improvement’ overall. The practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 June 2015

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bayswater Medical Centre on 4 June 2015. We inspected the main practice located at 46 Craven Road, W2 3QA and the branch practice located at 7 Golborne Road, W10 5PN. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe, effective, caring, responsive services and being well led. It was also inadequate for providing services for older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, appropriate recruitment checks on staff had not been undertaken prior to their employment.
  • Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and limited communication with staff.
  • There was insufficient assurance to demonstrate people received effective care and treatment. For example there was no information available to indicate that any patients with a learning disability had received an annual health check and review of their care.
  • Patients said they were treated with dignity and respect.
  • Patients said they experienced significant difficulties in booking an appointment and had to wait long periods of time to be seen for their appointment in the practice. The availability of GP appointments at the main and branch practice was unclear for patients.
  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

  • Ensure there is adequate clinical staff employed in the practice and with the right skills to meet the needs of patients. Ensure recruitment arrangements include all necessary employment checks for all staff and document all recruitment and employment information in staff files.
  • Ensure staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out their duties they are employed to perform including providing clinical care and treatment in line with national guidance and guidelines.
  • Ensure there are systems in place for effective care and monitoring of patients experiencing poor mental health (including people with dementia); those with circumstances that make them vulnerable; patients with long term conditions and patients identified as at risk.
  • Ensure audits of practice are undertaken, including completed clinical audit cycles to monitor and drive improvement in patient care.
  • Establish effective systems, including monitoring and regular audit of practice, to meet current guidance to ensure infection prevention and control measures are met and the cleanliness and hygiene of the practice is maintained and assured. Introduce a legionella risk assessment and related management schedule.
  • Make suitable arrangements for training staff in safeguarding adults and children.
  • Ensure arrangements are in place for annual testing of all electrical equipment.
  • Implement a safe system for medicines management including the development of a cold chain procedure and stock control of emergency medicines to ensure these are in date and fit for use.
  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision. Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which is reflective of the requirements of the practice. Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements. The service must seek and act on feedback from staff, patients and external agencies on the services provided and evaluate and improve their practice in respect of this information.

The areas where the provider should make improvement are:

  • Provide explicit information for patients on the practice website regarding GP appointments.
  • Develop a system for the effective identification and support of patients who are carers.
  • Ensure staff are familiar with organisations to signpost patients who are carers or patients who have experienced bereavement or are experiencing a significant health issue.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. Bayswater Medical Centre are not to carry out any regulated activities at the branch site and not to register any new patients at the main practice except for family members of existing patients for a period of six months.

On 8 June 2015 we served the practice a Section 31 of the Health and Social Care Act 2008 (“the Act”) notice to impose these conditions in relation to their registration as a service provider. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice